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mi  mil  mi  mi 
"HX64076342 
RA863.5V83  L33    The  mineral  waters  o 


The  Mineral  Waters  of  Vittel 

Grande  Source  *  Source  Salee 

THEIR  NATURE  AND  USES 


COMPILED   EXPRESSLY    FOR   THE 


MEDICAL  PROFESSION 


EDWARD  LASS  ERE 


J/MdJiSVrt 


_ 


Columbia  Sbtfuecritp 

intljeCttpoflUrttig0rk 

College  of  ^Ijpsicians  anb  burgeons 
Htfcrarp 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons  (for  the  Medical  Heritage  Library  project) 


http://www.archive.org/details/mineralwatersofvOOIass 


The  Mineral  Waters  of  Vittel 


GRANDE  SOURCE 

AND 

SOURCE    SALEE 

Their  Nature  and  Uses 


COMPILED    EXPRESSLY   FOR   THE 

MEDICAL   PROFESSION 

BY 

EDWARD   LASSERE 


U.  S.  Agency,  400  West  23rd  Street,  New  York 
EDWARD   LASSERE,  Ac;hnt 


© 


in 

CD 


CONTENTS 


«-£ 


Preface 


Other  Conditions 


PAGE 

-      4 


Vittel  Treatment    --            -  -  -  -  -  -  -5 

Characteristics  of  the  Waters  -  -  -  -  -  -      5 

Vittel  Treatment  at  the  Springs  -  -  -  -  -  -6 

Vittel  Treatment  at  Home  -  -  -  -  -  -  -6 

The  "Grande  Source"  Water         -  -  -  -  -  -  -7 

Gout        -  .  _  _  _  _  -  _  _      7 

Urinary  Disorders        --------      8 

Renal  Lithiasis  _______  -      8 

Pyelitis  -----_____g 

Cystitis  -------.__      g 

Vascular  Hypertension  -  -  _  -  -  -  -8 


9 


The  "Source  Salee"  Water            -            -            -            -            -            -  -10 

Hepatic  Conditions       -            -            -            -            -            -            -  -10 

Gastric  Disorders          -            -            -            -            -            -            -  -n 

Vittel  Treatment  in  Children     -            -            -            _            _            _  _i: 

Urinary  System            -            -            -            -            -            -            _  _i] 

Hepatic  System  --_--___ 

Digestive  System           -            -            -            -            -            -            -  -11 

"Notes  on  the  Uses  of  the  Vittel  Waters"         -            -            -            -  -     12 
By  H.  J.  Johnston-Lavis,  M.  D.,  D.  Ch.,  M.  R.  C.  S„  etc. 

Adjuvants  in  Vittel  Treatment  at  the  Springs          -            -            -  -     14 

Environment     -            -            -            -            -            _            _            _  -14 

Balneo-Therapy            -            -            -            _            _            _            _  -14 

Mech  a  no-Therapy        -            -            -            -            -            -            _  -14 

Warm  and  Superheated  Air    -            -            -            -            -            .  -15 

Massage  --------__    je 

Electric  Installations            -            -            -            -            -            -  -15 

Open-air  Exercises       -            -            -            -            -            _            -  -15 

Dieting  ------____    -g 

Regulation  Diets         -           -           -           -           -           .           _  -    16 

"Some  Examples  Illustrating  Cases  of  Chronic  Toxaemia  at  Vittel"  -    17 

By  II.  J.  Johnston-Lavis,  M.  I).,  D.  Ch.,  M.  K.  C.  S.,  etc. 

heb  Examples  Illustrating  Cases  of  Chronic  Toxaemia  at  Vittel"  -    25 
By  if.  j.  Johnston-Lavis,  m.  J>.,  D,  Ch.,  _f.  R.  c.  s.,  etc. 

Clinical  History  of  Various  Cases  treated  with  the  Vittel  Waters  -  -    31 
By  Dr.  F.  Constant,  0.  Paris,  France. 


PREFACE. 

THE  application  of  natural  mineral  waters  to  the  cure  or  relief  of  disease 
involves  much  more  complicated  considerations  than  is  sometimes 
supposed.  Mineral  waters  are  a  two-edged  weapon  demanding  the  most 
skilled  handling.  Hence  medical  men  who  send  patients  to  mineral-water 
health  resorts  should  be  well  acquainted  both  with  the  property  of  the  water 
at  the  resort  selected  and  with  the  ways  in  which  it  is  likely  to  be  used  by 
the  colleague  thereat  to  whom  they  entrust  their  patients. 

During  the  past  few  years  the  details  of  hydrotherapy  have  been  consider- 
ably modified  under  the  influence  of  various  authorities,  including  physicists  and 
scientific  chemists,  as  well  as  medical  men.  The  treatment  provided  now  is 
not  merely  curative,  but  also  prophylactic,  and  may  be  applied  with  advantage 
to  children  as  well  as  adults.  In  this  connection  a  statement  of  Professor  Lan- 
douzy  may  suitably  be  quoted: 

"What  is  necessary  is  that  the  medical  profession  should  learn  to  take 
advantage  of  natural  mineral  waters  and  the  resources  of  physio-therapy. 
If  the  visitors  to  mineral-water  health  resorts  included  a  larger  proportion 
of  children,  the  number  of  adult  visitors  would  in  a  few  decades  corre- 
spondingly decrease.  Those  who  otherwise  might  have  been  visitors 
would,  having  been  cured  in  childhood  of  their  original  weaknesses,  be 
less  prone  to  disorders  of  the  throat,  bronchi,  skin,  kidneys,  liver,  and 
stomach — less  affected  by  those  disease-originating  diatheses  which  children 
inherit  from  parents,  and  at  present  transmit  in  their  turn  to  their  own 
offspring,  because  not  submitted  to  the  redeeming  qualities  of  natural 
mineral  waters,  and  thereby  enabled  to  rid  themselves  of  their  ancestral 
defects." 

It  rests,  therefore,  with  practitioners  anxious  for  the  well-being  of  the 
race  to  transform  mineral-water  health  resorts  into  true  schools  of  hygiene, 
moral,  physical,  and  dietetic — into  schools  of  health  capable  of  correcting  both 
original  and  acquired  defects. 


VITTEL  TREATMENT. 


CHARACTERISTICS  OF  THE  WATERS. 

Of  the  numerous  springs  at  Vittel,  two  only  are  generally  utilized.  These 
are  the  Grande  Source  and  the  Source  Salee,  which  were  declarees  d'Utilite 
Publique  (declared  a  Public  Benefaction)  by  the  French  Government  (Minis- 
terial decree  of  Dec.  29th,  1903),  being  the  only  springs  at  Vittel  having  been 
considered  worthy  of  that  distinction. 

These  springs  present  the  rare  advantage  of  possessing  a  mineralization 
which  is  at  the  same  time  sufficient  and  not  excessive.  It  is  sufficient  because, 
contrary  to  certain  so-called  medicinal  waters,  of  which  the  mineralization 
is  two  or  three  times  less,  or  even  almost  nil,  the  Grande  Source  and  the 
Source  Salee  have  a  very  active  effect  upon  the  organism,  of  which  they 
excite  the  nutrition  and  from  which  they  clear  away  the  waste  caused  by  an  im- 
perfect assimilation.  Their  mineralization  is  not  excessive  because  they  do  not 
present  either  the  inconveniences  of  waters  too  highly  charged  with  sulphate 
of  lime,  a  therapeutic  agent  of  contestable  value,  but  also  and  especially  dif- 
ficult of  digestion,  nor  the  dangers  of  waters  too  strongly  alkaline,  which 
weaken  the  organism  and  provoke,  by  the  alkalinization  of  the  urine,  the  for- 
mation of  phosphatic  gravel,  which  unites  with  the  uric  and  oxalic  gravel, 
increasing  the  volume  of  the  stones.  In  short,  the  Grande  Source  and  the 
Source  Salee,  thanks  to  their  very  slight  tendency  to  liberate  free  carbonic 
acid,  never  provoke  dilation  of  the  stomach  as  do  effervescing  waters,  especially 
such  as  are  tampered  with  by  being  superaerated,  a  practice  which  is  con- 
demned by  high  medical  authorities.  Also  owing  to  these  numerous  advan- 
tages they  enjoy  the  rare  privilege  of  being  used  as  table  waters  with  marked 
medicinal  value. 

Technically  these  waters  may  be  described  as  mild  alkaline  bicarbonated 
sulphated  waters,  non-chloride  bearing.  The  most  dominant  and  characteristic 
feature  is  the  almost  total  absence  of  chloride  of  sodium  or  common  salt, 
making  these  almost  unique  among  mineral  waters.  This  absence  of  sodium 
chloride  renders  them  invaluable  in  all  kinds  of  kidney  troubles,  arterial  and 
consequent  heart  diseases,  neurasthenia,  juvenile  epilepsy,  etc.,  etc. 

5 


VITTEL  TREATMENT, 

AT  THE  SPRINGS. 

Vittel  treatment  is  primarily  treatment  by  diuresis,  the  springs  principally 
employed  being  two  in  number — Grande  Source  and  Source  Salee.  The  com- 
position of  the  waters  they  supply,  and  the  indications  for  their  respective  use, 
will  be  dealt  with  later  on.  The  average  length  of  a  cure,  or  course  of  treat- 
ment, is  twenty-one  days.  The  waters,  which  are  of  the  non-thermal  class, 
owe  their  action  to  their  temperature,  quantity,  and  mineral  contents.  When 
taken  on  an  empty  stomach,  they  stimulate  the  movements  of  that  organ  by 
bringing  about  contraction  of  its  muscles;  the  emptier  the  stomach,  the 
greater  the  rapidity  with  which  the  water  is  passed  onward  to  the  intestines. 
There  is  thus  no  delay  in  its  absorption  and  subsequent  elimination  by  the 
kidneys,  the  quantity  of  urine  passed  being  correspondingly  increased  and  the 
blood  thoroughly  cleansed. 

The  doses  required  vary  in  different  individuals  and  diseases;  no  general 
rule  as  to  the  dosage  would  apply  equally  to  all  cases.  Formerly,  when 
water  was  regarded  merely  as  a  means  of  washing  out  the  stomach  and  intes- 
tines, the  quantities  prescribed  were  comparatively  large,  but  they  are  now, 
whatever  their  amount,  well  within  the  limits  indicated  by  precise  physio- 
logical knowledge.  In  short,  the  doses  are  always  carefully,  and  in  some 
cases  minutely,  graduated. 

In  some  conditions  the  water  is  administered  on  an  empty  stomach  in 
the  morning;  in  others,  a  little  before  meal-times,  so  as  to  promote  the  secre- 
tion of  purer,  and  therefore  more  efficacious,  gastric  juice.  Whatever  the  dose 
for  the  day,  it  is  ordered  to  be  broken  up,  and  the  interval  between  the  drink- 
ing of  each  fraction  prescribed.  The  length  of  this  varies  with  each  patient 
and  each  disease.  The  commencing  doses  are  always  small,  and  are  increased 
little  by  little  as  the  system  becomes  accustomed  to  the  water.  Treatment  in 
bed  is  only  prescribed  in  certain  cases  of  vascular  hypertension,  which  are 
elsewhere   discussed. 

VITTEL  TREATMENT, 

AT  HOME. 

Since  the  Grande  Source  and  Source  Salee  waters  of  Vittel,  "thanks  to 
the  stability  of  their  composition  are  admirably  fitted  for  exportation  and  use 
at  a  distance"  (Prof.  Landouzy),  for  those  unable  to  take  the  cure  at  Vittel 
itself,  corresponding  results  may,  in  a  great  measure,  be  obtained  by  an  intel- 
ligent use  of  the  imported  waters,  as  by  treatment  at  the  Resort  itself. 

Being  bottled  very  carefully  and  under  conditions  which  obviate  all  risk 
of  contamination,  the  water  keeps  indefinitely.  No  other  spa,  indeed,  has  so 
far  attained  the  same  degree  of  perfection  in  the  mechanical  sterilization  of 
bottles  and  corks  and  in  the  securing  of  asepsis  in  filling  and  bottling  its 
waters  as  that  reached  at  Vittel;  the  methods  there  used  afford  the  consumer 
the  maximum  of  safety  in  this  respect.  In  a  pamphlet  published  a  few  years 
ago,  by  Dr.  H.  J.  Johnston-Lavis,  entitled  "Some  Truths  about  Vittel,  Con- 
trexeville  and  Martigny,"  speaking  of  the  bottling  arrangements  at  these  three 
stations,  he  expresses  himself  thus  concerning  those  at  Vittel: 

"At  Vittel,  the  bottle  as  it  arrives  from  the  factory  is  cleaned,  ster- 
ilized, then  brushed  and  rinsed  in  some  of  the  water  of  the  spring,  then 
filled,  capsuled,  burnished  and  labelled,  all  by  machinery.  The  corks  are 
previously  sterilized  by  superheated  steam.  In  fact,  some  10  or  12  min- 
utes converts  the  glass  maker's  product  into  a  filled  and  labelled  bottle  of 
the  Grande  Source  or  the  Source  Salee  that  will  keep  for  months  or  years, 
and  is  of  course,  free  from  contamination." 

Constantly  repeated  and  most  carefully  controlled  researches  prove  that 
even  after  the  lapse  of  two  years  or  more,  bottled  Vittel  water  shows  no 
change  whatever,  and  retains  all  its  properties,  provided  that  the  bottles  are 
stored  under   suitable  conditions. 


THE  "GRANDE  SOURCE"  WATER. 


The  first  Vittel  water  to  be  considered 
in  detail  is  that  supplied  by  the  spring 
known  as  Grande  Source.  Its  composition 
per  litre  (as  determined  when  application 
was  made  to  the  French  Government  for 
official  recognition  of  the  spring  as  one  of 
Public  Utility)    is  as  follows: 

Free  carbonic  acid o  "0475 

Carbonic  acid  in  combination ...  0  "3070 

Calcium  carbonate 0  "2994 

Magnesium  carbonate 0  '0392 

Ferri  carbonate 0  0032 

Calcium   sulphate o  -6288 

Magnesium  sulphate o  •  1923 

Lithium   sulphate 0  -0004.  8 

Sodium  chloride        \  T 

Potassium  chloride  j x  races 

Sodium  silicate 0  '0156 

Phosphoric  acid....  -\ 

Fluorin  I  Traces 

Alumen 1 

Magnesium   ) 

Organic  matter 0  -0205,  2 

Residue  at  1700  C 1  -2025 

The  indications  for  the  use  of  the  Grande 
Source  water  are  considered  in  the  follow- 
ing paragraphs. 


URIC    ACID   STONES 

ejected  at  Yittel  after  a  course  of  treatment 

by  the  Grande  Source. 

(Collection  of  Dr.  Patezon,  medical  inspector.) 


GOUT. 

Treatment  by  waters  of  the  alkaline  class  is  only  suited  to  chronic  gout 
in  weak,  anaemic  individuals,  but  this  is  not  the  case  with  Grande  Source  water. 
It  is  a  typical  specimen  of  the  "earthy"  class,  and  as  well  suited  to  robust 
persons,  whose  attacks  take  an  acute  form,  as  to  subacute  gout  in  the  weakly. 
On  this  point  Professor  Landouzy  says: 

"A  patient  subject  to  acute  gout  will  recover  on  paying  a  visit  to 
Vittel,  and  as  soon  as  his  attack  is  over  will  see  the  exudations  around 
the  affected  joints  quickly  reabsorbed.  On  the  other  hand,  a  subject  of 
chronic  gout  in  a  feeble,  anaemic  condition  should  go  there  as  long  as 
possible  after  his  last  definite  attack,  and  aim  at  preventing  any  further 
recurrence." 

But,  apart  from  definite  gout,  Grande  Source  water  is  indicated  in  sundry 
allied  conditions: 

1.  In  the  non-arthritic  complications  of  gout,  such  as  congestion  of  the 
liver,  neuralgia,  sciatica,  and  bronchial  catarrh.  On  this  point  it  may  be  men- 
tioned that  Galezowski,  the  ophthalmologist,  advises  treatment  by  waters  of 
this  class  in  conjunctivitis  and  iritis  of  gouty  origin,  especially  when  recur- 
rent, and  that  even  varix  and  phlebitis,  when  due  to  the  same  cause,  may  be 
included  among  the  conditions  which   benefit. 

2.  In  persons  threatened  with  artcrio-sclerosis  and  exhibiting  symptoms 
such  as  hypertension,  rapid  action  of  the  heart,  polyuria,  or  traces  of  albumi- 
nuria. These  cases  require  especial  care,  as  anj  increase  of  blood-pressure 
must  be  avoided,  particularly  if  a  lesion  of  the  aorta  has  already  been  es- 
tablished. 

3.  In  cases  of  gouty  albuminuria  associated   with   the  passage  of  oxalic 

or  uric  acid   gravel,  or  when   the  albuminuria  gl      merely   functional. 

But  even  gouty  albuminuria  of  apparently  permanent  character  and  associated 
with  oliguria  often  lessens  in  amount  or  disappears  altogether. 


URINARY  DISORDERS. 

Present  knowledge  of  the  etiology  of  oedema,  nephritis,  and  hypertension 
dictates  more  care  than  was  common  at  a  time  when  waters  of  the  earthy 
class  were  used  chiefly  as  a  means  of  increasing  the  permeability  of  the 
kidneys.  The  treatment  no  longer  aims  merely  at  washing  out  the  kidneys 
and  dissipating  fluids  diffused  throughout  the  tissues.  It  is  only  the  more 
lightly  mineralized  waters  of  this  class  that  are  of  service;  they  withdraw  by 
a  process  of  dialysis  some  of  the  sodium  chloride  impregnating  the  tissues, 
and  are  essential  in  dechlorhydration  treatment.  Hence  Grande  Source  water 
is  of  value  in  the  following  conditions:  (i)  In  albuminuria,  when  this  is  due 
to  irritation  rather  than  inflammation  of  the  kidney,  as  is  the  case  when  the 
primary  cause  is  friction  by  gravel,  especially  oxalic  acid  gravel.  Such  al- 
buminuria disappears  during  treatment.  (2)  In  slight  albuminuria,  either  of 
mechanical  origin  or  left  behind  by  a  bacterial  infection  or  pregnancy,  and 
unaccompanied  either  by  polyuria  or  any  noteworthy  change  in  the  general 
composition  of  the  urine  or  increased  blood-pressure.  (3)  In  cyclical  albumi- 
nuria. And,  finally  (4),  as  advised  by  Castaigne,  in  cases  of  chronic  nephritis 
presenting  evidence  of  retention  of  urea,  as  distinct  from  dropsical  albuminuria. 

RENAL  LITHIASIS. 

Renal  lithiasis,  whether  of  the  uric  acid  or  oxalic  acid  type  and  due  to 
causes  such  as  incomplete  proteid  combustion,  or  of  the  phosphatic  type  and 
due  to  local  morbid  conditions  in  the  urinary  passages  is  amenable  to  treat- 
ment by  the  water  of  the  Grande  Source  of  Vittel.  In  the  first  class  of  case 
the  object  kept  in  view  is  counteraction  of  the  effect  of  the  arthritic  diathesis 
by  stimulating  the  vital  functions,  especially  that  of  the'  liver,  and  thus  secur- 
ing more  perfect  metabolism.  In  the  second,  the  aim  is  to  promote  renal 
secretion,  modify  the  condition  of  the  lining  membrane  of  the  kidneys  and 
urinary  passages,  and  secure  evacuation  of  mucus  and  sand. 

According  to  von  Noorden,  the  favorable  action  of  earthy  waters  in  the 
former  class  is  due  to  their  holding  back  in  the  intestines  any  acid  phosphate 
of  calcium;  hence  dibasic  sodium  phosphate  predominates  in  the  urine,  which 
becomes  less  acid.  In  virtue  of  the  same  consideration,  the  Grande  Source 
water  must  be  regarded  as  equally  indicated  in  persons  of  arthritic  type,  who, 
without  suffering  obviously  from  gravel,  pass  excessively  acid  urine  which 
eventually  deposits  red  sand,  and  who  are  the  subjects  either  of  obesity,  dys- 
pepsia, or  migraine. 

Patients  affected  with  gravel  and  subject  to  attacks  of  lumbar  pain  are 
suitable  for  treatment. 

PYELITIS. 

Pyelitis  is  amenable  to  treatment  by  the  Grande  Source  water,  both  when 
complicated  by  phosphatic  deposits — the  evacuation  of  these  being  hastened 
by  the  water — and  especially  when  simple  and  unaccompanied  by  gravel.  In 
these  cases  the  diuresis  effected  acts  as  a  kind  of  natural  drainage. 

CYSTITIS. 

Cases  of  subacute  or  chronic  cystitis  without  obstruction  are  favorably 
affected.  The  pyuria  diminishes  and  the  contractility  of  the  bladder  improves 
under  the  influence  of  small  doses  given  for  a  considerable  period. 

VASCULAR  HYPERTENSION. 

There  is  some  degree  of  inadequacy  of  renal  action  in  most  cases  of 
hypertension,  and  this  makes  them  amenable  to  treatment  by  diuresis.  The 
arterial  hypertension  is  at  first  merely  transitory,  the  observed  pressure  being 
sometimes  high,  sometimes  low.  It  is  in  this  presclerotic  stage,  when  there 
is  nothing  more  "than  functional  evidence  of  the  vascular  trouble,  and  when 
neither  cardiac  nor  renal  lesions  so  far  exist,  that  Huchard  thinks  the  treat- 


ment  best  applied,  more  especially  since  the  gravel  or  gout  almost  always 
associated  with  the  condition  are  themselves  amenable  to  the  Grande  Source 
water.  For  some  years  past  it  has  been  observed,  it  may  be  noted,  that 
lowering  of  tension  occurs  when  chlorides  or  uric  acid  are  freely  discharged. 
Another,  but  less  common,  type  of  sclerosis  also  improves  under  Vittel 
Grande  Source  treatment — cases  of  hypertension  accompanied  by  the  passage 
of  large  quantities  of  urine  containing  few  solids.  In  such  patients  the  per- 
meability of  the  renal  tissues  is  diminished,  and  the  output  of  chlorides  and 
of  nitrogen  compounds  is  always  subnormal.  This  is  the  class  of  cases  in 
which  treatment  in  bed  is  desirable;  the  good  effect  is  quickly  evidenced  by 
increase  in  the  total  renal  output  both  of  solids  and  water,  and  prognosis 
may  be  based  on  this  fact. 

OTHER  CONDITIONS. 

There  are  sundry  other  conditions  in  which  use  of  the  Grande  Source 
water  is  indicated.     The  following  in  particular  may  be  noted: 

Glycosuria. — In  glycosuria  associated  with  obesity,  gravel,  gout,  or  other 
evidence  of  arthritism,  if  the  sugar  is  of  alimentary  origin,  it  is  usual  to  see 
it  decrease  and  sometimes  totally  disappear  during  digestion.  The  co-exis- 
tence of  moderate  albuminuria  is  not  a  counter-indication. 

Obesity. — In  cases  of  obesity  in  persons  who  are  distinctly  arthritic  in 
diathesis,  even  though  free  from  its  common  sequences.  In  these  patients 
the  treatment  may  be  supplemented  by  physio-therapeutic  measures. 

Dermatoses. — Certain  dermatoses  of  general  origin  benefit,  as  also  do 
certain  cases  of  migraine  allied  in  some  degree  to  arthritism  by  being  as- 
sociated with  overfeeding  or  a  sedentary  life. 


yiffm 


THE  "SOURCE  SALEE"  WATER, 


BILIARY  STONES 

ejected  at  Vittel  after  a  course  of  treatment 

by  the  Source  Sal6e. 

(Collection  of  Dr.  Pate'zon,  medical  inspector.) 


The  other  Vittel  water  is  known  as  Source 
Salee.      Its    composition    per    litre    is    as 

follows  : 

Free  carbonic  acid o  '0585 

Carbonic  acid  in  combination...  0-4200 

Calcium  carbonate o  -3230 

Magnesium  carbonate 0  -1294 

Ferri  carbonate o  -0003 

Calcium  sulphate o,-6i78 

Magnesium  sulphate 0  '5805 

Lithium  sulphate o  -0007, 9 

Sodium  chloride        ]  ~, 

Potassium  chloride  j  races 

Sodium   silicate 0  -0307 

Phosphoric  acid....   \ 

Lithia (_  „ 

Alumen X   Traces 

Manganese ' 

Organic  matter 0  -0300,  1 

Residue  at  1700  C 2  7260 


HEPATIC  CONDITIONS. 

The  disorders  amenable  to  treatment  by  the  Source  Salee  water  are  certain 
types  of  biliary  lithiasis. 

The  following  are  the  types  in  question: 


1.  Cases  of  arthritic  lithiasis  in  persons  not  constitutionally  predisposed 
thereto,  but  who  present  evidence  of  imperfect  or  retarded  metabolism. 

2.  Cases  of  repeated  biliary  colic;  in  order  to  provoke  a  mild  attack 
during  which  the  biliary  concretions  will  pass  on  without  constitutional  dis- 
turbance. In  these  cases  alkaline  waters  afford  no  visible  result,  but,  on  the 
contrary,  Source  Salee  treatment  generally  ends  in  the  expulsion  of  the  stone, 
if  one  exists. 

3.  Convalescence  from  biliary  colic;  the  improvement  in  these  is  very 
rapid.  The  extent  to  which  the  Source  Salee  water  favors  the  secretion  of 
healthy  bile  can  be  seen  in  the  subjects  of  biliary  fistula. 

4.  Mild,  slow  cases  of  almost  apyretic  angiocholitis.     In  these 

"mineral-water  treatment  as  an  adjuvant  to  other  measures  is  capable 
of  affording  most  excellent  results....  If  the  hepatic  cellules  require 
specially  tender  handling,  Vittel  treatment  should  be  selected."  (Gil- 
bert and  Lereboullet:  Rap.  Con.  Franc,  de  Med.  Geneve,  1908.) 

5.  Biliary  lithiasis  associated  with  constipation  due  to  lack  of  bile.  In 
these  cases  alkaline-water  treatment  is  distinctly  contra-indicated,  but  that  of 
Vittel  Source  Salee  is  especially  valuable,  more  particularly  in  persons  with 
irritable,  easily  congested  livers. 

6.  Biliary  lithiasis  associated  with  a  gouty  articular  or  nephritic  mani- 
festation. The  combined  disorders  can  be  treated  simultaneously,  if  desired, 
by  the  Grande  Source  and  Source  Salee  waters. 

7.  Liver  disorders  in  feeble  and  anaemic  persons.  Mathieu  (in  L'Hygiene 
du  Goutteux)  has  pointed  out  that  in  liver  cases  in  nervous,  thin,  weakly  sub- 
jects the  wasting  and  exciting  action  of  Carlsbad  treatment  must  be  shunned, 
and  water  of  the  Vittel  type  selected. 


Other  hepatic  conditions  suitable  for  treatment  are  congestion  of  the 
liver  in  gouty  persons,  accompanied  by  deficient  performance  of  its  functions 
and  cholaemia,  whether  idiopathic  or  consecutive  to  infective  lesions  of  the 
bile  canals. 

GASTRIC  DISORDERS. 

Also  susceptible  to  treatment  by  the  Source  Salee  water  are  cases  of 
motor  dyspepsia  associated  with  gastric  atony  and  biliousness,  and  the  same 
form  of  dyspepsia  in  gouty  persons  and  those  with  either  ordinary  or  nerve 
manifestations   of   arthritism. 

The  fact  that  constipation  due  to  insufficient  biliary  secretion  may  be 
successfully  treated  has  already  been  mentioned.  Certain  types  of  muco-mem- 
branous  enteritis,  associated  either  with  biliary  lithiasis  or  uric  acid  retention, 
also  prove  amenable  to  treatment  by  Source  Salee  water. 


VITTEL  TREATMENT  IN  CHILDREN. 

Arthritism  in  children  is  invariably  the  outcome  of  heredity.  Such  children, 
to  adopt  Grandmaison's  phrase,  are  born  "arthritisable" — that  is  to  say,  with 
a  morbid  predisposition  in  the  cellular  metabolism  of  certain  tissues  which, 
unless  counteracted,  is  bound  to  manifest  itself  sooner  or  later.  Hence,  if  heed 
is  to  be  paid  to  the  views  emphatically  expressed  by  Prof.  Landouzy  in  the 
passage  quoted  in  the  Preface  to  this  brochure,  Vittel  treatment  may  well 
be  prescribed  for  the  children  of  gouty  parents,  especially  those  who  as  infants 
have  presented  evidence  of  their  inheritance  of  the  diathesis  in  question. 
Among  the  more  special  indications  are  the  following: 


URINARY  SYSTEM. 

(i)  Cases  of  alternating  urine,  this  being  sometimes  concentrated  and  rich 
in  urates,  sometimes  clear  and  of  low  specific  gravity.  It  is  always  a  proof 
of  irregular  kidney  action.  (2)  Troubles  of  micturition,  including  excessive 
frequency,  incontinence,  and  vesicular  spasm.  In  these  cases  the  urine  is 
almost  always  abnormal,  being  either  too  rich  in  urates  or  in  phosphates,  or 
too  acid.  These  manifestations  of  arthritism  have  been  shown  by  Comby  to 
occur  even  in  early  infancy,  and  to  be  the  cause  of  the  discomfort  some  babies 
show  in  various  ways  when  passing  water.  (3)  Cases  of  gravel  during  child- 
hood and  adolescence. 

HEPATIC  SYSTEM. 

Treatment  by  the  Source  Salee  is  also  indicated  in  cases  of  biliary  lithiasis, 
though  this  is  rare  in  young  people. 


DIGESTIVE  SYSTEM. 

rders  associated  with  insufficient  secretion  of  bile  and  slight  hepatic 
engorgement,  such  as  irregular  or  perverted  appetite,  alternating  costiveness 
and    i  of   bowels,   and   chronic    muco-membranous    enteritis.      As   an 

adjuvant  to  general  hygienic  treatment  of  these  conditions,  Vittel  Waters 
arc  of  ^reat  value.  The  same  remark  applies  to  migraine  and  skin  lesions  in 
children  dependent  on   imperfect  performance  of  nutritive  functions. 


NOTES  ON  THE  USES  OF  THE  VITTEL  WATERS. 

By  H.  J.  Johnston-Lavis, 

M.D.,  D.Ch.,  M.R.C.S.,  Engl.,  Etc.    Professor  (Fellow)  Royal  University  of  Naples. 
Senior  Consulting  Physician  R.  Victoria  Memorial  Hospital  (Nice-Beaulieu). 


We  have  at  Vittel  several  waters,  and  consequently  a  considerable  scope 
for  their  use  in  different  classes  of  ailments.  Of  late  years  a  great  change  has 
come  over  hydrotherapeutic  treatment.  The  violent,  highly  mineralized  waters 
of  Vichy  or  Carlsbad,  Bath,  or  Harrogate,  etc.,  are  being  replaced  by  milder 
waters,  the  effects  of  which  may  be  a  little  slower  in  bringing  about  a  cure, 
but  have  the  advantage  in  that  cure  being  more  substantial  and  permanent. 
They  do  not  expose  the  invalid  to  the  secondary  effects  of  the  more  heroic 
water  treatment,  and  are  without  the  disagreeable  after  results  that  so  often 
follow  the  employment  of  too  drastic  measures.  This  is  no  doubt  the  outcome 
of  the  change  in  our  habits.  Gout  fifty  years  ago  was  in  general  a  widely 
different  thing  from  what  it  is  to-day,  and  so  treatment  then  and  now  must 
be  different. 

The  Grande  Source,  almost  unlimited  in  amount,  gushes  out  at  a  tem- 
perature of  n°  C.  and  practically  never  varies  in  volume  or  temperature 
during  any  season  of  the  year.  It  is  par  excellence  the  spring  where  uric 
acid  and  other  waste  products  or  toxines  and  the  diseases  associated  with 
their  presence  are  treated.  Whatever  our  views  may  be  as  to  cause  and  effect 
of  them  in  arthritism,  gout,  the  gouty  state  with  its  near  allies  or  manifesta- 
tions, neurasthenia,  neuritis,  neuralgias,  sciatica,  certain  dyspepsias,  intestinal 
catarrh  and  above  all  the  different  kidney  troubles,  calculi  be  they  uric,  uratic, 
oxalic,  and  most  of  the  rarer  forms  of  stone  or  gravel,  we  are  struck  by  the 
specific  action  of  these  springs  in  producing  the  remarkable  results  that  yearly 
build  up  the  reputation  of  Vittel.  Even  a  layman  who  stops  a  few  weeks  at 
Vittel  hears  quite  enough  from  the  patients  themselves  to  convince  him  of  the 
large  number  of  cures  and  cases  of  marked  improvement.  Chronic  forms  of 
nephritis,  adolescent  albuminuria,  cystitis,  prostatis,  are  all  amenable  to  its 
beneficent  action. 

The  age  of  a  man  has  been  aptly  defined  as  the  age  of  his  arteries.  Of 
late  years  the  researches  of  Prof.  Huchard  and  others,  including  some  of  the 
physicians  of  Vittel,  have  clearly  demonstrated  that  these  waters  have  a 
specific  action  in  permanently  lowering  excessive  blood  pressure  and  in  the 
treatment  of  the  troublesome  and  dangerous  disease  of  arteriosclerosis  or 
hardened  arteries.  In  the  first  stage  the  arteries  are  kept  in  a  state  of 
spasmodic  contraction  and  consequently  high  tension  from  the  circulation 
within  them  of  blood,  loaded  with  toxines  or  poisonous  substances.  This 
eventually  leads  to  degenerative  changes  in  the  arterial  walls  with  higher  and 
more  obstinate,  increased  blood  pressure.  Finally  from  the  excessive  strain 
so  thrown  upon  the  arteries  they  either  burst  and  cause  an  apoplexy,  or  the 
heart  at  last  fails  in  consequence  of  the  endless  excessive  work  thrown  upon 
it  by  the  resistance  of  these  hardened  blood  vessels  to  its  pumping  action. 

It  is  particularly  in  the  first  stage  of  this  ailment  that  the  Grande  Source 
is  of  so  much  use.  The  water  is  invaluable  in  the  second  stage  and  affords 
benefit  if  used  with  great  care  even  in  the  final  condition  of  failing  heart. 
Prof.  Huchard  and  many  other  physicians  have  sent  numbers  of  patients  here 
each  year,  and  I  find  that  few  o-r  none  go  away  without  marked  benefit. 

Another  type  of  ailment,  neurasthenia,  so  common  nowadays,  I  pointed 
out  some  years  ago  as  being  particularly  ameliorated  by  a  visit  to  Vittel. 
Neurasthenia  in  my  earlier  professional  days  I  looked  upon  as  an  almost  in- 


curable  disease.  From  the  moment  that  I  realized  that  it  was  a  form  of 
toxaemia  or,  to  put  in  vulgar  parlance,  "goutiness"  of  the  nervous  system,  the 
whole  scene  changed  and  I  consider  myself  very  unfortunate  if  any  patient 
suffering  from  "nerves"  does  not  go  home  after  a  suitable  cure  at  Vittel, 
adapted  to  each  special  case,  practically  well,  or  at  any  rate  far  on  the  road  to 
complete  restoration. 

Another  ailment  which  shows  marked  improvement,  I  have  noticed, 
among  the  few  cases  that  have  come  here  more  by  accident  than  intent,  is 
juvenile  epilepsy.  One  or  two  cases  that  did  the  cure  here  completely  lost 
their  fits,  and  others  have  been  markedly  improved.  Probably  the  relief  of 
the  toxaemic  condition,  which  plays  such  an  important  part  in  epilepsy,  and 
the  dechlorurizing  effect  of  Vittel  water  will  explain  this. 

In  that  condition  of  chronic  toxaemia  called  "goutiness"  the  Grande  Source 
has  its  largest  scope.  In  the  articular,  muscular  and  fibrous  forms  such  as 
lumbago  it  acts  as  a  specific.  It  is  equally  effective  in  the  very  varied  visceral 
manifestations  such  as  chronic  bronchitis,  some  forms  of  asthma,  some  liver 
and  stomach  ailments.  In  neuritis  not  only  does  it  render  great  service  in 
the  gouty  form  but  finds  its  use  in  chronic  nerve  inflammation  from  other 
causes,  such  as  malaria,  alcohol,  etc.  Finally  many  remarkably  resistent  skin 
diseases  are  vanquished  by  a  cure  at  Vittel. 

Its  continued  use  as  a  table  water,  far  from  presenting  any  inconvenience 
whatsoever,  is  eminently  favorable  to  the  stomach,  the  secretions  and  the 
muscular  tone  of  which  become  improved. 

The  Source  Salee  is  composed  of  the  same  elements  as  the  Grande  Source, 
but  much  more  higly  mineralized  in  magnesia.  It  derives  its  reputation  from 
the  marked  curative  effects  it  has  in  different  ailments  of  the  alimentary  canal. 
Flatulent  dyspepsia  often  quite  disappears  after  a  short  course,  and  the  same 
may  be  said  of  mucous  or  membranous  colitis  where  it  may  in  addition  to 
drinking  be  used  for  intestinal  lavage  with  marked  benefit.  Chronic  constipa- 
tion cases  and  those  of  recurring  appendicitis  have  found  much  benefit  by  its 
use.  It  is  however  in  its  influence  on  the  liver  that  the  therapeutic  value  is 
most  strikingly  evident.  Liver  congestion,  whether  due  to  alcohol,  sedentary 
habits,  malaria,  Malta  fever  or  other  causes,  rapidly  improves.  The  number 
of  cases  of  jaundice  that  are  cured  and  of  gall  stones  that  are  got  rid  of  every 
year  by  its  use  brings  number  of  victims  of  that  terrible  complaint  to  Vittel 
each  season.  Certain  forms  of  diabetes  of  hepatic  or  pancreatic  origin  are  quite 
cured  by  the  use  of  the  Source  Salee,  and  in  consequence  of  its  power  of  re- 
moving abdominal  congestion  it  is  used  with  much  benefit  in  piles  and  in 
convalescence  from  malarial  and  other  tropical  ailments.  Large  numbers  of 
obese  people  resort  to  it  to  reduce  their  weight.  Finally  in  certain  forms  of 
chronic  bronchial  catarrh  and  asthma,  probably  of  a  gouty  strain,  marked 
improvement  follows  its  use. 

The  water  of  the  Source  Salee,  laxative  but  not  purgative,  exercises  an  elec- 
tive action  upon  the  liver,  the  more  precious  because  it  does  not  provoke  any 
symptoms  of  anaemia  or  weakness,  but  is  on  the  contrary  very  well  tolerated  by 
the  organism  and  particularly  by  the  stomach. 

Let  me  further  remark  that  the  water  of  the  Source  Salee  is  not  at  all 
salt,  but  on  the  contrary  very  agreeable  to  drink.  The  bicarbonates  of  lime, 
of  magnesia,  of  iron  and  of  lithine  give  it  tonic  and  depuratory  properties 
which  render  it  digestive  and  make  it  a  very  agreeable  and  salutary  table 
water;  mixed  with  wine  which  it  does  not  change  in  any  way,  it  counteracts 
the  acidity  of  the  liquids  in  the  stomach,  excites  the  appetite,  stimulates  the 
digestion,  and  maintains  the  regularity  of  the  functions  of  the  liver  and  of  the 
intestines;  it  is  specially  recommended  to  women  whose  sedentary  habits 
predispose  them  to  debility  of  the  digestive  tube. 

This  incursion  into  the  scientific  domain  may  be  concluded  by  the  remark 
that  the  Vittel  waters  keep  remarkably  well  in  bottles,  and  that  they  have  pre- 
served up  to  the  present  their  superiority  from  a  bacteriological  point  of  view, 
verified  in   1894  by  the  Aca<b'rnic  de  Medecine. 


13 


ADJUVANTS  IN  VITTEL  TREATMENT 
AT  THE  SPRINGS. 

Mineral-water  treatment  is  far  from  being  the  sole  factor  in  the  patient's 
cure  at  Vittel,  for  Professor  Landouzy  has  shown  that  much  importance  is 
to  be  attached  to  "the  adjuvants  to  the  special  treatment — namely,  the  en- 
vironment and  general  treatment  of  the  patient  during  the  few  weeks  that 
he  is  being  submitted  to  the  action  of  the  water  intus  et  extra." 

ENVIRONMENT. 

Climate. — The  climate  of  a  place  demands  almost  the  first  consideration 
when  arthritic  cases  and  exhausted  constitutions  are  in  question. 

Altitude. — On  this  point  it  may  be  said  that  Vittel,  situated  as  it  is  at  an 
altitude  of  some  1,160  feet  on  the  edge  of  the  forest  zone  of  the  Vosges  and 
Haute-Saone  region,  enjoys  a  Continental  climate  in  all  its  purity.  It  is  never 
very  hot,  even  in  the  height  of  summer. 

Surroundings. — Built  as  it  is  in  the  open  country,  at  a  distance  from  any 
large  town,  Vittel  suggests  in  its  general  appearance  a  vast  garden,  with 
borders  merging  insensibly  into  surrounding  uplands  of  decided  beauty. 

Natural  Drainage. — The  ground  has  a  sufficient  fall  to  provide  excellent 
natural  drainage,  while  desirable  dryness  of  soil  is  further  secured  by  the  small 
woods  and  pine  plantations  amid  which  the  resort  lies. 

Atmosphere. — The  woods  and  the  neighboring  great  forests  play  another 
useful  part;  the  ozone  which  they  generate  in  such  abundance  is  a  constant 
safeguard  of  atmospheric  purity. 

Ozone. — The  proximity  of  the  Vosges  Mountains  also  contributes  to  the 
supply  of  ozone;  one  physical  effect  of  this  when  present  in  abundant  quantity 
has  been  shown  by  Hayem  to  be  an  increase  in  sleeping  power.  The  truth 
of  this  observation  has  been  clearly  proved  by  the  experience  of  Vittel. 

Temperature. — The  fact  that  the  air  temperature  is  always  cool,  even  on 
the  hottest  days  of  summer,  is  a  further  factor  in  successful  treatment. 

In  short,  the  climate  is  such  as  to  diminish  cutaneous  respiration,  and 
facilitate  renal  secretion  and  the  general  nutrition  of  the  system. 

BALNEO-THERAPY. 

In  view  of  its  action  on  tissue  change,  the  value  of  balneo-therapy  cannot 
be  overlooked  in  the  treatment  of  disorders  of  nutrition.  Very  rightly,  there- 
fore, much  attention  is  paid  to  the  subject  at  Vittel.  A  building  equipped  with 
all  the  most  modern  appliances  of  balneo-therapy  has  been  provided,  and  the 
arrangements  made  secure  that  all  bath  and  douche  treatment  shall  be  applied 
in  thoroughly  scientific  fashion.  The  mineral  water  for  bath  use  is  stored  at 
as  low  a  temperature  as  possible  in  a  series  of  cisterns  placed  at  different 
heights  from  the  ground,  in  order  to  secure  the  precise  degrees  of  pressure 
required  to  meet  the  varying  needs  of  patients  and  the  stage  which  their  cure 
has  reached.  The  water  is  raised  to  the  required  temperature  by  means  of 
hot-air  coils,  but  this  heat  is  never  allowed  to  pass  8o°  Centigrade,  so  that 
there  may  be  no  interference  with  the  gaseous  and  mineral  contents  of  the 
water.  Each  douche  apartment  has  its  own  independent  supply,  in  order  that 
no  undesigned  alteration  in  temperature  or  pressure  may  occur.  Close  to  the 
douching-rooms  are  a  series  of  vapor,  Roman,  carbonic,  acid,  electric,  and 
douche-massage  baths.  Finally,  by  way  of  making  the  arrangements  thoroughly 
complete,  rooms  are  provided  for  vaginal  and  ascending  douches. 

The  excellence  and  comprehensive  character  of  the  balneo-therapeutic 
arrangements  make  it  possible  to  secure  for  each  patient  precisely  the  treat- 
ment he  requires,  and  led  to  Bardet  saying  at  the  end  of  a  tour  round 
European  health  resorts  that  he  had  never  seen  the  desiderata  of  balneo-therapy 
so  well  appreciated  and  carried  out  as  at  Vittel. 

MECHANO-THERAPY. 

As  Vittel  patients  commonly  require  special  forms  of  exercise,  one  hall 
in  the  Cure-House  has  been  fitted  up  with  mechano-therapeutic  appliances 
of  all  kinds.     Not  only  do  these  appliances  make  up  for  any  lack  of  inclina- 

14 


tion  for  exercise,  but,  since  the  muscular  contractions  they  produce  are  regular, 
a  health}'  circulation  is  promoted,  the  terminations  of  nerve  filaments  stimu- 
lated, and  due  oxidation  obtained.  Another  advantage  is  that  the  amount  of 
work  done  by  the  muscles  can  be  graduated  with  almost  mathematic  precision 
according  to  the  needs  of  each  patient  at  the  moment,  besides  being  made 
either  purely  passive,  purely  active,  or  a  mixture  of  the  two.  The  passive 
movements  are  specially  useful  in  dealing  with  the  muscular  and  articular 
results  of  old  gout,  for  the  daily  movements,  in  addition  to  freeing  stiffened 
joints  and  stretching  contracted  tendons,  lead  to  progressive  movement  in 
the  nutrition  of  the  tissues  concerned,  and  thus  form  a  valuable  adjuvant  to 
Vittel   treatment. 

WARM  AND  SUPERHEATED  AIR. 

The  visitors  to  Vittel  include  many  sufferers  from  chronic  pain,  in  whom 
warm  air  applications  as  an  adjuvant  in  treatment  proves  of  value.  Patients, 
for  instance,  with  neuralgia  of  rheumatic  or  gouty  origin,  general  muscle 
pains,  and  lumbago  of  obstinate  character,  are  often  quickly  cured  by  com- 
bining Vittel  treatment,  warm-air  applications,  and  vibratory  massage;  the 
relief  from  pain  is  in  many  cases  immediate,  and  becomes  permanent  after  a 
certain  number  of  sittings. 

In  cases  of  long-standing  sciatica,  chronic  arthritis,  stiff  and  ankylosed 
joints,  superheated  air  is  to  be  preferred.  After  a  few  applications  coupled 
with  massage,  movement  becomes  freer,  the  local  circulation  is  improved,  and 
exudations  rapidly  clear  up.  Indeed,  as  an  adjuvant  to  Vittel  treatment,  the 
indications  for  the  use  of  either  warm  or  superheated  air  are  numerous.  It 
constitutes,  perhaps,  the  most  important  physical  remedy  available,  and  in 
combination  with  massage  and  mineral  water  may  be  regarded  as  essential 
in  the  treatment  of  arthritics. 

MASSAGE. 

Massage  is  frequently  a  useful,  and  sometimes  an  indispensable,  adjuvant 
to  treatment.  In  cases  of  defective  nutrition  the  system  must  be  freed  from 
the  waste  matter  encumbering,  it.  This  is  the  task  of  Vittel  water,  and  it  is 
aided  therein  by  massage,  which  makes  these  waste  matters  re-enter  the  cir- 
culation, and  thus  facilitates  their  elimination  by  diuresis.  At  the  same  time 
it  reflexly  stimulates  the  sympathetic  system  and  improves  the  general  circula- 
tion. Massage  also  comes  usefully  into  play  in  cases  of  constipation  due  to 
insufficiency  in  bile  secretion.  On  these  Vittel  water  has  a  special  action,  and 
massage  of  the  liver  assists  it.  Finally,  massage  is  of  importance  in  dealing 
with  the  cases  of  hypertension  which  come  to  Vittel,  for  the  work  both  of 
Cautru  and  Huchard  has  proved  that  its  action  on  the  vasomotor  system  is 
in  the  nature  of  a  preventive,  and  thus  a  valuable  ally  to  the  rest  of  the 
treatment. 

ELECTRIC   INSTALLATIONS. 

The  electric  appliances  in  use  differ  in  no  wise  from  those  found  in  well- 
equipped  hospitals  and  nursing  homes  in  large  cities.  In  the  treatment  of 
joint  conditions  and  of  the  gouty  and  neuralgic,  electric  baths  play  a  consider- 
able part,  sometimes  as  local,  sometimes  as  general  applications.  They  are 
also  employed  in  cases  of  obesity  and  hypertension  in  order  to  provoke  per- 
spiration and  increase  the  output  of  metabolic  products.  The  X-ray  outfit 
provided  often  proves  of  much  assistance  in  confirming  or  negativing  the 
existence  of  renal  or  hepatic   calculi. 

OPEN-AIR  EXERCISES. 

The  provision  for  what  has  been  termed  "Oertel  treatment"  is  of  a  satis- 
factory kind,  promenades  of  .ill  gradients  being  available.  Originally  this 
system  of  graduated  exercise  was  reserved  for  myocardiac  cases,  but  is  now 
being  employed  with  increasing  frequency  in  all  conditions  associated  with 
imperfect  nutrition,  and  also  in  the  obese,  especially  when  accumulations  of 
fat  round  the  heart  an  ed.      In  the  case  of  those  whose  exercise  need 

not  be  precisely  regulated,  golf,  clay-pigeon  shooting,  and  whatever  more 
active  -ports,  such  as  tennis,  may  b(  considered  desirable,  form  valuable  aids 
in  treatment,  especially  as  they  all  centre  round  the  establishment  itself. 

15 


DIETING. 

Increasing  importance  is  attached  to  the  dieting  of  patients  at  mineral- 
water  resorts,  and  at  Vittel  careful  dieting  is  held  to  be  an  essential  part  of 
treatment.  As  practised  at  Vittel,  an  additional  advantage  is  secured;  the 
attention  paid  to  the  subject  helps  to  educate  the  patient  in  matters  dietetic. 
Before  his  treatment  is  over  he  realizes  not  only  what  his  diet  should  be,  but 
also  that  adherence  to  it  entails  no  particular  difficulty  or  privation. 

It  is  to  Germany  that  a  good  many  advances  in  the  dieting  of  spa  patients 
are  due;  but  the  Germans,  it  must  be  added,  have  endeavored  to  exploit  a 
belief  that  only  in  Germany  can  patients  be  suitably  dieted.  Hence  at  most 
mineral-water  health  resorts  uncooked  fruit,  even  though  perfectly  ripe,  is 
excluded  from  the  diets  permitted,  while  sausages  et  id  genus  omne  figure 
freely  therein.  At  least  one  reason  for  this  fact  is  that  while  Germany  is  not 
particularly  well  off  for  fresh  fruit,  food  of  the  other  kind  mentioned  is  plenti- 
ful and  cheap.  At  Vittel  things  are  otherwise  managed.  Dieting,  when  it  is 
required,  is  strictly  observed  there,  but  no  attempts  are  made  to  enforce  one 
common  diet  for  all  alike,  as  is  the  case,  for  instance,  at  St.  Nectaire,  where 
about  80  per  cent,  of  all  the  patients  are  albuminurics,  or  as  at  Chatel-Guyon, 
where  there  are  only  four  never-varying  diets.  At  Vittel  there  is  such  variety 
in  the  disorders  treated  that  systems  of  the  kind  mentioned  would  be  un- 
desirable, even  if  it  were  not  recognized  how  right  Landouzy  was  when  he 
said  that  it  was  illogical  to  confine  a  patient  to  the  same  food  during  the 
whole  of  his  treatment,  since  the  real  needs  of  his  system  must  vary  with  the 
progress  of  his  case. 

In  view  of  these  considerations,  Vittel,  with  the  co-operation  and  advice 
of  the  medical  men  established  there,  has  adopted  the  following  plan  in  cater- 
ing for  the  food  needs  of  its  invalid  guests.  Since  a  majority  of  all  Vittel 
patients  are  sufferers  from  one  form  or  another  of  arthritism,  the  foodstuffs 
used  in  the  regulation  diets  are  chosen  from  among  those  suitable  to  the  com- 
mon run  of  such  cases.  This  important  differentiation  among  foodstuffs  being 
established,  the  bill  of  fare  for  the  day  is  in  its  essential  constituents  always 
suitable  for  an  average  case  of  gout  or  gravel,  and  it  becomes  quite  an  easy 
task  to  alter  the  dishes  placed  before  each  patient  so  as  to  make  them  precisely 
suited  to  his  particular  needs,  whether  his  case  be  one  of  lithiasis — uric  acid, 
oxalic  acid,  phosphatic,  or  biliary  in  type — or  whether  his  diathesis  manifests 
itself  in  disorders  of  his  cutaneous  or  nervous  system,  or  of  his  circulation. 
It  is  only  the  arthritic  patient  with  glycosuria  whom  the  foodstuffs  in  question 
do  not  habitually  suit,  and  for  whom  other  foodstuffs  must  be  chosen  in 
view   of  the   necessity   of  restricting  his  intake   of   carbohydrates.      It   should 

dded  that  all  the  dishes  entering  a  regulation  diet  are  cooked  on  special 
lines. 

This  system  meets  the  needs  of  the  great  majority  of  all  patients,  and  it 
>6  only  exceptionally  that  the  regulation  diets  do  not  suit  a  patient,  and  special 
Arrangements  have  to  be  made  for  him;  in  such  cases  his  meals  are  prepared 
according  to  the  specific  instructions  of  his  medical  attendant. 


REGULATION   DIETS. 

To  facilitate  the  preparation  of  regulation  diets,  each_  visitor  needing  to 
"be  dieted  is  handed  by  his  medical  attendant  a  list,  on  which  is  marked  what 
iood  materials  are  suitable  for  him,  or  otherwise,  and  this  in  his  turn  the 
visitor  hands  to  the  head  waiter  of  his  hotel. 

The  value  of  the  system  of  Vittel  has  been  so  well  demonstrated  that  it 
"has  now  been  adopted  at  some  other  health  resorts.  The  regulation  diets  give 
rise  to  no  difficulty,  the  menus  proving  so  acceptable  to  the  patients  that 
when  their  time  at  Vittel  is  up  they  are  quite  prepared  to  adhere,  if  need  be, 
to  the  same  form  of  food  for  as  long  a  time  as  may  be  desirable. 

16 


(Reprinted  from  the  British  Medical  Journal  of  July  23rd,  1910.) 

SOME  EXAMPLES  ILLUSTRATING   CASES   OF 
CHRONIC    TOXEMIA    AT  VITTEL, 

By  H.  J.  Johnston-Lavis,  M.D.,  D.Ch.,  M.R.C.S.,  etc., 

Professeur  Agrege,  Senior  Consulting  Physician  to  Q.  Victoria  Memorial  Hospital,  Nice: 
Consulting  Physician  to  the  "  litablissement,"  VITTEL. 


Perhaps  in  the  whole  history  of  the  growth  of  a  spa  or  hydro-mineral 
station  none  can  compare  with  the  remarkable  rapidity  with  which  Vittel  has 
jumped  into  fame.  Ten  years  since  it  was  known  to  comparatively  few  phy- 
sicians, and  ranked  as  a  fourth  or  fifth  rate  station  so  far  as  its  resources  and 
number  of  visitors  were  concerned.     It  now  stands  in  the  very  first  rank. 

I  have  practised  there  seven  seasons,  and  done  two  cures  there  myself 
annually,  and  may,  therefore,  claim  to  speak  with  some  experience.  I  propose 
to  select  a  few  of  my  cases  from  one  season's  (1909)  practice,  and  to  point 
out  the  results  as  an  illustration  of  the  beneficent  action  of  the  cure  in  some- 
what varied  ailments.  The  cases  of  ''physiological  disequilibrium"  and  ailments 
that  are  relieved  by  Vittel  treatment,  of  however  varied  facies,  may  all  be 
summed  up  as  the  result  of  chronic  toxcemias  due  to  either  perverted  nutrition, 
defective  metabolism,  or  incomplete  elimination.  This  condition,  which  we 
English  physicians  denominate  as  "goutiness"  and  the  French  medical  man 
as  arthritique,  is  ill  expressed  by  such  terminology.  All  originate  in  an  excess 
of  one  or  more  of  the  normal  constituents  of  the  blood  or  the  presence  of 
abnormal  ones.  When  we  look  at  these  different  disturbances  of  the  physiologi- 
cal balance  we  shall  all  the  more  clearly  appreciate  the  close  association  of 
many  different  ailments.  We  shall  also  be  able  to  comprehend  how  a  cure 
such  as  Vittel  is  one  of  the  most  effective  and  rational  methods  of  restoring 
physiological  equilibrium. 

Who  can  draw  the  border  line  between  acute  and  chronic  gout,  calculosis, 
some  forms  of  nephritis,  arterio-sclerosis,  neurasthenia,  asthma,  chronic  bron- 
chitis, some  dyspepsias  and  entero-colitis,  many  skin  diseases,  neuritis,  some 
rheumatisms,  etc.? 

When  I  have  at  other  times  sustained  this  thesis,  critics  have  held  me  up  to 
ridicule.  My  answer  has  been,  Think  over  it,  and  tell  me  why  we  so  often 
find  several  such  states  associated  in  the  same  individual  at  once  or  alternating 
with  each  other,  and  why  the  same  cure  with  suitable  modifications  is  so  ef- 
ficacious in  relieving  or  curing  each  of  these  troubles. 

All  the  analyses  are  of  the  entire  and  carefully  collected  quantity  of 
twenty-four  hours.  They  are  made  in  my  own  private  laboratory,  fitted  with 
the  most  modern  and  approved  apparatus  by  my  analyst,  Dr.  Burrais,  of  the 
Pasteur  Institute.  He  knows  nothing  of  the  cases,  and  is  therefore  quite  free 
from  any  personal  equation  modifying  the  result.  All  the  results  are  cal- 
culated on  the  personal  equation  of  each  individual  based  on  weight,  height, 
and  age.  Where  extraordinary  results  are  obtained,  both  of  us  repeat  the 
determination.  All  calculations  are  based  on  the  personal  coefficient.  I  have 
much  pleasure  in  thanking  him  for  his  valuable  and  skilful  assistance. 

Case  No.    i. 

J.  M.,  aged  58,  6  ft.,  weight  77  kilos,  sent  by  the  late  Dr.  Radcliffe  Crocker. 
Has  suffered  for  years  from  eczema  on  neck,  fingers,  toes,  and  fork  of  legs. 
He  complained  of  feeling  stiff  in  his  movements,  lacking  energy,  and  always 
tired.  Has  also  patches  of  psoriasis  on  knees.  Two  fingers  and  one  toe  sup- 
purating around  nails,  the  region  of  which  is  red,  swollen,  and  angry.  There 
is  no  syphilitic  history.  The  son  is  a  fine  specimen  of  an  officer  in  the  Guards, 
wife    in    good    health.      Patient    has    always    been    temperate,    has    fairly    good 

17 


digestion,  but  takes  an  aperient  every  morning,  "which  keeps  him  all  right." 
His  skin  acts  freely.  He  is  otherwise  a  strong,  healthy  man.  He  has  "been 
twice  to  Homburg,  and  three  times  to  Schinznach,  with  little  benefit. 

On  July  18th,  day  after  arrival,  had  a  mean  blood  pressure  of  135  mm. 
His  urine  is  represented  in  the  diagram  illustrated  here,  which  is  remarkable 
by  the  enormous  amount  of  solids,  composed  of  all  the  elements  of  the  urine, 
but  specially  chlorides,  which  were  73  per  cent,  in  excess.  His  urea-uric  acid 
coefficient  is  sensibly  normal,  but  both  are  increased  nearly  thirty  per  cent, 
above  what  they  should  be. 

After  a  few  days  he  was  drinking  1.800  c.cm.  of  Grande  Source  before 
breakfast,  and  900  c.cm.  in  the  afternoon.  The  skin  was  kept  active  with  baths 
at  360  C,  and  a  low  semivegetarian  diet  ordered,  excluding  salt  as  much  as 
possible. 

Another  twenty-four  hour  urine  analysis,  made  on  August  9th,  one  day 
after  the  cure  was  stopped,  shows  a  remarkable  change.  The  curve  has  the 
same  general  form,  but  approaches  quite  near  to  the  normal  line.  Solids  have 
fallen  from  204  to  125  per  cent.,  acidity  from  144  to  no  per  cent.,  urea  from 
128  to  90  per  cent.,  uric  acid  and  chlorides  to  normal,  and  phosphates  to  9  per 
cent,  below  normal. 


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J.  M.,  July  20th,  1909. 
Traces  of  some  reducing  material  ( ?  glu- 
cose). Slight  traces  of  true  and  modified 
biliary  pigments  and  of  scatol.  Abundant 
deposit  of  urates  and  some  pavement  epi- 
thelium.     Purins    0.518    per    24    hours. 


August  9th,  1909. 
True    biliary    pigments    in    traces,    as    also 
faint    reaction    of    scatol.      Urates    and    cells 
much  less.     Purins   0.689  per   24  hours. 


Simultaneously  with  this  all  his  feelings  of  stiffness,  loss  of  energy,  etc., 
have  disappeared,  and  all  his  skin  lesions  are  rapidly  healing. 

I  think  we  have,  here  a  case  of  excessive  assimilation  which  led  up  to  a 
state  of  autointoxication  in  which  the  skin  was  most  affected,  but  he  was  on 
the  verge  of  an  outbreak  of  joint,  muscular,  and  nervous    trouble. 

The  lixiviating  effect  of  a  rapidly  absorbable  and  rapidly  excretable  non- 
chloride-bearing  waters  is  striking. 

The  purin  bodies  as  a  whole  seem  to  have  increased  at  the  end  of  the 
cure.  Whether  we  can  interpret  this  as  increased  production  or  increased 
excretion  of  a  retained  stock  could  only  be  determined  by  ulterior  analyses, 
which  unfortunately  could  not  be  obtained. 

The  following  three  cases  I  have  chosen  because  they  consist^  of  father, 
mother,  and  adult  daughter  living  under  sensibly  the  same  conditions,  and 
furthermore  that,  as  they  enjoyed  Vittel  so  much,  they  stopped  on  for  some 
weeks  after  their  cure,  and  the  second  urine  analysis  was  made  at  a  considerable 
interval  after  their  "cures"  had  stopped.  These  are  rare  opportunities,  and  I 
think  worthy  of  study. 

18 


Dr.  Curgenven,  who  sent  them  to  me,  says:  "Mr.  S.  had  an  attack  of  car- 
diac weakness  and  irregularity  about  two  years  ago — a  very  irregular  pulse, 
high  arterial  tension,  a  tendency  to  dyspnoea,  and  a  dilated  stomach;  this  was 
caused,  I  think,  by  living  at  too  high  a  pressure,  and  too  generous  a  diet.  With 
rest  and  careful  dieting  he  soon  improved.  A  year  ago  he  had  a  mild  attack 
of  basal  pneumonia,  and  he  has  occasional  attacks  and  threatenings  of  lum- 
bago." 

Case  No.  2. 

The  patient,  Mr.  S.,  is  a  hale  and  hearty  looking  man,  aged  60.  His 
digestion  is  fairly  good,  except  for  a  little  flatulence;  the  bowels  regular.  Car- 
diac area  faintly  increased  when  the  heart  is  working  at  its  normal  rhythm. 
When  I  made  my  first  examination,  on  July  23rd,  his  pulse  was  running  at  an 
almost  uncountable  rate.  After  various  attempts  and  dodges  I  made  it  192. 
While  making  notes  of  this  and  other  observation,  occupying  about  three 
minutes,  I  returned  again  to  feel  the  pulse,  when  to  my  astonishment  it  was 
a  steady,  vigorous  beat  of  72.  His  mean  blood  pressure  was  140  mm.  He 
himself  attributed  his  cardiac  condition  to  extra  smoking,  he  having  filled  in 
all  the  time  of  travelling  by  doing  it.  He  was  suitably  dieted,  and  alcohol, 
tobacco,  tea  and  coffee  restricted.     At  the  end  of  three  weeks  all  his  cardiac 


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Mr.  C.  S-,  July  25th,  1909. 
Modified  biliary  pigments  fairly  abundant ; 
indican  marked  ;  scatol  slight  traces.  Purins 
0.798.  Abundant  crystals  of  uric  acid  and 
urates,  and  also  oxalates.  Some  epithelial 
cells. 


August    23rd,     1909. 
Modified    biliary   pigments   normal ;    indican 
fairly   marked:    scatol   traces.      Purins   0.717. 
Irate  of  soda,  very  few  oxalates,  and  epithe- 
lial   cells. 


symptoms  had  disappeared,  his  digestion  was  all  right;  he  expressed  himself 
as  feeling  quite  well.  His  pulse  was  still  at  72,  but  his  blood  pressure  had 
fallen  to  115.     Several  days  after  stopping  the  cure  this  favorable  state  persisted. 

The  urine  analysis  before  the  beginning  of  the  cure  sItjdws  a  large  excess 
of  nutritive  substances  and  their  waste  products  that  the  organism  was  making 
a  great  effort  to  excrete.  In  the  urine  analysis  after  the  end  of  the  cure  we 
see  that  the  solids,  which  were  133  per  cent.,  have  fallen  to  just  below  normal. 
The  acidity  has  been  but  little  reduced,  only  amounting  to  12  per  cent.  less. 
Urea  was  reduced  from  127  to  8'j  per  cent.,  and  uric  acid  to  normal.  Before 
the  cure  urea  was  much  higher  than  the  uric  acid,  whereas  after  the  ratio  was 
reversed,  showing  the  great  utility  of  the  waters  in  restoring  the  proper  ratio 
of  these  two  bodies;  in  fact,  this  is  almost  universal,  and  clinically  I  have 
always  found  that  when  marked  benefit  has  accrued  this  has  been  the  case,  and 
where  absent  the  cure  has  been  of  less  use. 

The  chlorides  and  phosphates  had  fallen  considerably  below  normal.  Diet 
will  explain  the  former  but  the  latter  is  more  difficult  to  interpret. 

Here  we  have  an  illustration  of  four  distinct  elements  leading  to  chronic 
mia — exc  noking,   alcoholism,   feeding,   and   mental  activity.     This 


19 


led  to  general  circulatory  spasm,  in  which  both  arteries  and  heart  were  affected. 
That  true  arterio-sclerosis  had  set  in  is  disproved  by  the  rapid  fall  of  blood 
pressure  under  treatment,  but  no  doubt  a  continuance  of  the  patient's  mode 
of  living  will  soon  lead  to  irreparable  artery  and  heart  changes. 

Case  No.  3. 

Mrs.  S.,  wife  of  the  last  patient,  aged  45,  of  slim  build,  is  congenitally  par- 
tially deaf;  is  a  very  nervous  woman,  partly  due  to  that  defect;  gets  bad 
rheumatic  pains,  especially  in  shoulders,  and  stiff  neck,  which  are  specially 
excited  by  champagne  and  strawberries.  She  has  occasional  bad  headaches 
but  is  a  great  cigarette  smoker,  and  has  marked  arcus  senilis.  Heart  sounds 
normal  except  that  aortic  valves  closed  with  a  slight  clang.  Has  had  several 
children  living,  and  two  bad  miscarriages  and  fibroids.  Menopause  at  42. 
Digestion  is  good  but  has  to  take  cascara.  Sleep  moderate,  perspiration  very 
free.  Takes  plenty  of  exercise — golf,  etc.  Urine  analysis  at  commencement 
of  cure  shows  solids  and  acidity  too  high,  urea  15  per  cent,  below  normal  and 
uric  acid  47  per  cent,  above — a  very  great  disproportion.  Besides  the  cure 
she  had  some  general  massage  with  Vigorax,  a  dietary  in  which  fats  and 
oxalate-bearing  foodstuffs  were  excluded.  The  result  of  this  was  a  vast  im- 
provement in  her  health — she  became  less  nervous,  her  pains  disappeared  as 


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Mrs.   S.,   July   25th,    1909. 
Traces    of    true    and    modified    biliary    pig- 
ments.    Scatol  reaction  very  marked.    Purins 
0.922.     Fair  quantity  of  urates,  oxalates,  and 
pavement  cells. 


September  3rd,  1909. 
Traces  of  true  and  modified  biliary  pig- 
ments, and  traces  of  scatol.  Purins  0.206. 
Urate  of  soda  fairly  abundant ;  only  a  very 
few  oxalates.  Pavement  epithelium  cells  and 
rhomboidal  cells. 


well  as  her  headaches.  A  second  analysis  made  some  time  after  the  cure 
terminated  shows  that  both  the  quantities  and  ratio  of  uric  acid  and  urea  have 
been  readjusted  to  "practically  normal. 

In  this  case  we  have  a  chronic  toxaemia  due  to  incomplete  metabolism, 
urea  being  replaced  by  an  excessive  production  of  uric  acid  and  oxalates.  The 
cure  has  resulted  in  the  rise  of  urea  to  above  normal,  coincident  with  the  fall 
of  uric  acid  to  normal  and  the  almost  total  disappearance  of  the  oxalates.  The 
purins  as  a  whole  fell  to  less  than  a  quarter  of  what  they  were  before  treat- 
ment. How  much  of  this  was  due  to  the  food  consumed  it  is  difficult  to  say, 
yet  both  husband  and  wife  were  following  much  the  same  menu  at  the  hotel. 


Case  No.  4. 

Miss  S.,  the  daughter,  aged  25,  weighed  79  kilos,  and  is  for  her  height  and 
age  obviously  obese,  so  differing  from  her  parents  and  also  a  younger  sister 
who  accompanied  the  family.     As   a  girl  she  was   always  anaemic,  has   some 


dysmenorrhoea,  but  loses  little.  Had  measles  five  years  ago,  and  gets  a 
delicate  throat  and  is  hoarse  when  tired  or  cold,  which  she  attributes  to  that 
disease.  Suffers  at  times  from  facial  neuralgia.  Mumps  three  years  ago;  has 
facial  neuralgia  since.  Three  years  ago  suffered  from  rheumatic  pains.  Leads 
a  very  active  life.  Digestion  is  good;  the  bowels,  once  troublesome,  are  now 
all  right.  She  is  a  small  eater  and  deep  sleeper.  Mean  blood  pressure  130  and 
an  arrhythmic  pulse  of  80.  Physical  examination  showed  no  apparent  cause 
for  this. 

The  twenty-four  hour  urine  analysis  at  the  beginning  of  the  cure  is  very 
interesting.  The  volume  is  60  per  cent,  below  normal,  due,  I  believe,  to  the 
stupid  superstition  that  privation  of  fluids  helps  to  thin  people.  This  old  and 
unscientific  doctrine  still  has  a  hard  and  dangerous  hold  upon  the  public,  and 
I  am  sorry  to  say  is  still  a  fetish  of  many  medical  men.  Only  those  who  have 
constantly  to  diet  people  can  appreciate  the  difficulties  in  overcoming  popular 
prejudices  when  one  has  to  directly  traverse  the  orders  of  one  of  one's  col- 
leagues. 

The  patient's  excretion  of  solids  is  20  per  cent,  below  normal,  due  in  great 
part  to  an  insufficiency  of  the  vehicle  water,  but  also  to  the  low  chloride  as- 
similation. Acidity  is  26  per  cent,  above  normal,  whilst  urea  is  only  a  little 
above  one-third  of  the  normal  amount,  whilst  uric  acid  is  30  per  cent,  above 
normal. 


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Miss  S.,  July  25th,  1909. 
Both  true  and  modified  biliary  pigments 
abundant ;  no  indican,  but  scatol  abundant. 
Purina  0.244.  Urates  abundant,  large  crys- 
tals of  uric  acid  and  some  small  oxalates 
and   numerous  pavement  cells. 


September    1st,    1909. 
True   and    modified    biliary    pigments    slight 
traces,    and    traces    of    scatol    only.      Purins 
0.664.      Urate  of   soda,   rare   crystals   of  uric 
acid,   no   oxalates. 


The  patient  is  a  small  salt  eater,  probably  in  harmony  with  a  defective 
assimilation  of  salt.  The  phosphates  are  also  34  per  cent,  below  normal.  The 
urine  is  burdened  by  urates,  uric  acid,  oxalates,  biliary  pigments,  scatol,  etc. 

The  second  analysis,  made  some  time  after  the  cure  had  finished  but  with 
the  patient  otherwise  living  under  exactly  similar  conditions,  shows  a  curve 
much  more  approaching  the  straight  line  representing  normal,  though  still 
showing  defective  assimilation,  but  to  a  much  less  marked  extent.  Biliary  pig- 
ments and  scatol  had  markedly  diminished,  but  strangely  the  purin  bodies 
were  nearly  tripled,  probably  from  some  exogenous  source.  The  further 
diminution  in  chlorides  was  probably  partly  due  to  diminished  intake  and  con- 
siderable losses  by  the  skin,  as  the  patient  was  doing  several  hours  of  tennis 
besides  being  massaged. 

During  the  cure  her  weight  fell  from  79  kilos  to  77-450,  and  continued  to 
diminish,  but  I  have  no  record  of  what  it  really  was  on  her  departure   from 


Vittel.     She  declared  herself  perfectly  well,  much  more  capable  of  energy,  and 
all  her  functions  in  good  order. 

In  this  case  we  have  another  example  of  perverted  assimilation  and  defec- 
tive metabolism  where  the  part  most  assailed  seems  to  have  been  the  adipose 
tissues. 


Case  No.  5. 

Miss  B.,  aged  24,  had  malaria  as  a  child,  but  has  had  no  traces  for  many 
years.  As  a  big  girl  had  eczema  very  badly,  but  that  has  gone  long  since. 
Jbour  years  since  had  "neuritis"  in  the  right  arm,  supposed  to  be  due  to  tennis. 
No  other  region  was  involved.  She  is  nervous,  neuralgic,  rheumatic,  has  some 
fullness  of  the  eyes  not  amounting  to  exophthalmos,  but  no  other  thyroid 
symptoms.  Her  digestion  is  described  as  perfect,  bowels  fairly  regular  and 
general  health  very  good. 

Tjh^  Urine  analysis  before  the  cure  proved  to  be  one  of  the  most  remark- 
able I  have  come  across.  The  solids  were  en  masse  about  normal  though  the 
volume  was  54  per  cent,  above.  Acidity  was  39  per  cent,  below  normal  and 
urine  36  per  cent,  below,  whilst  the  amount  of  uric  acid  reached  the  astounding 


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Miss    B.,    July    31st. 
Traces    of    true    and    modified    biliary    pig- 
ments,    and     also     very    slightly     of     scatol. 
Purins,   0.380.      Urate   of   soda.      Great  num- 
bers of  epithelial   cells. 


August  20th,   1909. 
Biliary   pigments,   true   and   modified,   very 
abundant,     as    also     scatol.       Purins,     0.904. 
Urates   and   epithelial   cells   abundant. 


figure  of  116  per  cent,  above  normal,  chlorides  only  just  10  per  cent,  below, 
and  phosphates  41  per  cent,  below. 

In  the  second  analysis,  a  day  or  two  after  the  cure  was  finished,  the  urinary 
curve  approaches  sensibly  to  that  of  normal,  acidity  is  now  only  minus  24  per 
cent,  and  urea  18  per  cent,  below  normal,  a  gain  of  18  per  cent.  Uric  acid 
has  fallen  practically  to  normal— plus  8  only.  Still,  it  is  too  high  for  the 
amount  of  urea,  and  I  think  another  week  or  ten  days'  cure  would  have  been 
advisable. 

Strangely,  with  this  enormous  output  of  uric  acid  her  blood  pressure  was 
but  120  mm.,  with  a  capillary  reflex  of  3^2,  and  pulse  of  80.  At  the  end  of  the 
cure,  with  the  enormous  debacle  of  uric  acid,  her  blood  pressure  was  reduced 
to  115,  which  I  look  upon  as  normal  for  my  apparatus. 

At  the  end  of  the  cure  she  described  herself  as  perfectly  well  and  vigorous 
— fit  for  any  undertaking. 

The  great  increase  of  purins  is  again  an  illustration  of  the  inscrutability 
of  their  amount  in  relationship  to  other  physiological  processes. 


Case  No.  6. 

The  next  example  I  propose  to  put  before  you  is  interesting  from  several 
points  of  view.  He  is  a  typical  example  of  that  fat  form  of  Frenchman  that 
the  English  caricaturist  delights  in;  secondly,  he  is  mayor  of  the  town,  and 
has  never  drunk  an}-  other  water  but  Vittel,  though  that  appears  to  have  been 
a  most  rare  occurrence;  lastly,  he  has  been  and  is  a  most  intense  brain  worker, 
always  living  under  high  pressure.  He  is  a  big  and  rapid  eater,  could  not 
be  called  intemperate,  but  drinks  heartily  and  takes  no  physical  exercise.  I 
have  known  him  for  years,  and  foresaw  what  was  coming.  He  is  jovial,  good 
tempered,  with  his  enormous  charge  of  work  as  a  busy  lawyer,  administrator 
of  the  town,  and  magistrate. 

Mons.  H.  G.  rises  at  5  a.  m.,  writes  at  his  desk  till  8  a.  m.,  then  takes 
cafe-au-lait,  one  cup  and  a  roll.  He  continues  the  work  at  his  office  till  midday 
and  then  eats  a  good  lunch  with  wine  followed  by  black  coffee. 

In  the  afternoon  does  either  office  work  or  goes  in  his  motor  car  to  dif- 
ferent clients  of  the  region  for  business,  and  takes  during  the  afternoon  a 
black  coffee  and  two  or  three  glasses  of  beer. 

At  7  p.  m.  he  dines,  usually  with  a  soupe-au-lait,  with  much  bread,  noodles, 
rice,  and  other  farinaceous  food.  After  dinner  plays  cards  or  other  house 
amusements;  during  the  season  goes  almost  nightly  to  the  theatre.     Most  of 


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Mons.  G.,  June  27th,  1909. 
Evident  traces  of  glucose  after  defalcation 
with  a  lead  salt.  Biliary  pigments,  true 
and  modified,  well  marked.  Indican  abundant. 
Scatol  very  abundant.  Purins  1.147.  Urate 
of  soda  very  abundant,  forming  almost  the 
totality  of  the  deposit ;  a  few  cells,  uric 
acid  crystals  in  rosettes  rather  numerous 
and   oxalate  of  lime   fairly   abundant. 


September  6th,  1909. 
No  traces  of  glucose.  True  biliary  pig- 
ments very  slight.  Modified  biliary  pigments 
well  marked.  Indican  fairly  abundant. 
Scatol  abundant.  Purins  0.770.  Urate  of 
soda,  uric  acid  and  oxalates  but  a  fraction 
of    what    was    found    in   first   analysis. 


my  consultations  with  him  were  in  the  entre-actes.  He  is  a  good  sleeper,  seven 
to  eight  hours,  but  a  small  smoker,  and  a  great  lover  of  sweets. 

On  June  22nd  he  consulted  me  at  my  house,  having  come  to  the  end  of 
his  tether.  He  has  been  getting  daily  stiffer,  less  capable  of  exertion,  gets 
sleepy  and  incapable  of  concentrating  his  mind,  is  always  tired,  and  is  rapidly 
increasing  in  weight — he  now  weighs  115  kilos,  his  height  being  1.68  metres, 
and  his  age  50.  The  family  history  is  good,  but  several  of  his  relations 
were  fat. 

His  blood  pressure  was  only  130  mm.,  but  his  heart  muscle  obviously 
failing.  His  capillaries  are  much  .dilated,  giving  him  a  very  flushed  and  con- 
gested appearance. 

The  urine  analysis  is  remarkable  as  showing  the  fluid  starvation,  the  re- 
latively high  acidity,  urea  26  per  cent,  below  normal,  uric  acid  19  per  cent, 
above,  insufficient  chlorides,  and  phosphates  25  per  cent,  below  normal,  the 
latter,  no  doubt,  due  to  imperfect  phosphatic  assimilation,  with  the  resultant 
failing  brain   activity. 


2.3 


He  was  ordered  to  do  the  cure,  take  either  walking,  cycling,  or  physical 
training  exercise  in  the  mechanotherapeutic  institute.  He  was  ordered  a  diet 
chiefly  of  meat,  fish,  and  fowl,  green  vegetables,  except  the  oxalate-bearing 
ones,  fresh  fruit  and  in  compote  sweetened  with  saccharine,  with  the  exception 
of  grapes,  bananas,  figs,  and  other  fruits  of  this  kind.  A  little  dry  wine  was 
allowed.     Milk,  butter,  fats,  farinaceous  foods,  sweets,  disallowed. 

For  the  first  month,  though  fairly  obedient  for  his  dietary,  he  took  his 
waters  irregularly  and  did  no  exercise.  His  general  state  improved,  but  there 
was  little  diminution  of  weight.  He  bore  badly  electric  light  baths,  feeling 
faint;  but  with  shorter  ones,  and  at  a  lower  temperature,  was  able  to  continue. 

Girths  and  Weights. 


Date. 


June  24th 

July  4th 

July  25th 

September  8th 


Chest. 


Cm. 
1 12 

112 

109 
104 


Waist. 


Cm. 
116 

"3 

105 
106 


Hips. 


Cm. 
117 

117 

"3 

107 


Weights. 


Kilos. 
105 

105 

101 

95 


The  result  in  general  health  was  remarkable;  he  has  gained  all  his  elasticity 
of  movements,  his  mental  activity  and  promptness,  and  describes  himself  as 
feeling  much  younger.  His  circulation  is  better,  his  blood  pressure  has  fallen 
5  mm.;  his  pulse  is  now  48,  but  strong  and  vigorous. 

The  urine  analysis  of  September  6th  is  a  curious  study,  but  is,  I  believe,. 
partly  due  to  the  large  amount  of  animal  food  he  was  taking. 

CONCLUSIONS. 

I  have  not  given  any  example  of  a  large  number  of  cases  of  renal  calculus 
and  other  renal  and  bladder  troubles.  These  cases  usually  show  marked  im- 
provement, and  often  their  symptoms  disappear  for  years  or  entirely,  whilst 
others  only  show  temporary  advantage.  I  do  not  consider  that  these  cases- 
should  be  reported  till  two  or  three  years  after  manifestations  have  disap- 
peared. 

Chronic  nephritis  and  arterio-sclerosis  are  two  groups  of  maladies  that 
show  marked  improvement.  Professor  Huchard,  who  has  devoted  so  much 
attention  to  arterio-sclerosis  and  subsequent  heart  failure,  sends  many  dozens 
of  patients  here,  with  marked  advantage.  He  and  others  who  hold  the  toxi- 
alimentary  view  as  to  the  main  causation  of  that  disease  explain  the  action 
of  the  waters  as  being  what  I  will  call  vehicular,  or,  in  other^  words,  their 
flushing  effect.  I  quite  agree  that  is  an  important  element  of  their  eliminating 
mechanism,  but  I  think  that  there  are  two  others  that  apply  to  both  kidney 
and  arterial  degeneration.  First,  these  non-chloride  bearing  waters  lixiviate 
the  excess  of  that  salt  out  of  the  system  in  a  dilute  form,  and  by  so  relieving 
the  kidneys  of  a  heavy  secretory  work  allow  them  time  and  energy  to  expel 
the  toxic  substances  that  their  excessive  chloride  work  prevented  them  from 
performing.  In  the  next  place  the  assimilable  lime  salts,  to  which  so  much 
attention  has  been  drawn  of  late,  may  also  take  a  therapeutic  share  in  the 
effect. 

Of  neurasthenia  I  haA'e  always  personally  held  the  toxaemic  view,  and  in 
all  the  cases  of  that  disease  treated  by  these  waters  I  have  had  unfailing  suc- 
cess. The  group  of  ailments  which  we  call  neurasthenia  is  so  polymorphous 
and  requires  such  a  long  probation  time  to  be  declared  as  cured,  that  they  are 
difficult  to  give  striking  examples  of.  This  is  all  the  more  so  that_  in  most 
cases  beyond  the  nervous  and  mental  instability  there  are  other  organic  distur- 
bances requiring  accessory  treatment,  and  then  the  problem  of  which  did  the 
work  becomes  a  very  involved  one.  Such  diseases  as  so-called  gouty  bron- 
chitis as  well  as  asthma,  obviously  two  toxsemic  diseases,  show  remarkable  im- 
provement and  often  cure,  but  here  again  the  probation  period  should  be  not 
less  than  a  year. 


24 


During  several  years'  practice  I  have  had  a  few  young  epileptics  who  came 
to  accompany  their  parents.  I  was  asked  whether  the  cure  would  do  them 
good,  to  which  I  replied  that  unquestionably  for  their  general  health  it  would. 
In  three  cases  my  astonishment  was  great  at  seeing  their  fits  diminish  in 
number  and  disappear  without  bromides;  in  two  others  this  drug  became  much 
more  effective.     In  several  other  cases  only  slight  improvement  accrued. 

What  is  the  meaning  of  this?  Is  it  due  to  the  removal  of  toxic  substances, 
to  the  presence  of  which  many  authors  attribute  the  epilepsy,  or  is  it  due  to 
the  lixiviation  of  the  sodium  chloride,  which  Vidal  and  others  have  shown  to 
tear  some  relation  to  these  explosive  motor  storms? 

I  am  sorry  that  the  few  opportunities  of  observing  this  disease  at  Vittel 
prevents  any  useful  study  of  the  effect  of  the  cure  in  these  cases.  It  would 
be  well  worth  the  while  to  send  any  such  cases  which  might  open  up  a 
valuable  method  of  treatment  for  this  troublesome  disease. 


(Reprinted  from  the  British  Medical  Journal  of  February  3rd,  1912.) 

FURTHER  EXAMPLES  ILLUSTRATING  CASES 
OF  CHRONIC  TOXEMIAS  AT  VITTEL. 

By  H.  J.  Johnston-Lavis,  M.D.,  D.Ch.,  M.R.C.S.,  etc., 


In  July,  1910,  I  was  able  to  bring  forward  a  series  of  typical  cases  from 
my  practice  at  Vittel  during  the  previous  season  (1909).  That  paper  led  to  a 
number  of  inquiries  from  many  medical  brethren,  most  of  whom  asked  for 
more.  Some  varieties  of  chronic  toxaemias  were  not  represented,  and  I  have 
tried  in  the  present  notes  to,  in  part,  fill  up  these  gaps. 

In  practice  at  such  a  place  one  finds  a  large  number  of  cases  of  a  non- 
descript character,  or  at  least  appearing  to  be  so  to  our  imperfect  knowledge 
or  our  insufficient  means  of  determining  in  detail  the  loss  of  physiological 
balance  or,  in  other  words,  the  disease,  which  makes  them  appear  to  us  as 
an  uncoordinated  group  of  symptoms.  Such  indefinable  cases  represent  a 
large  part  of  one's  practice;  they  do  the  cure,  get  relief  of  their  symptoms, 
and  go  on  their  way  contented.  I  do  not  feel  justified  in  quoting  such  cases, 
as  they  would  rather  tend  to  confuse  our  minds  than  to  push  our  observations 
and  deductions  onward  along  the  path  of  precise  knowledge. 

I  have  therefore  limited  these  new  examples  of  cases,  with  one  exception, 
to  definite  morbid  entities,  to  illustrate  one  or  the  other  ailment  that  is  dig- 
nified by  a  name  and  presumed  to  be  of  known  pathology.  Like  those  of  the 
first  series,  their  treatment  is  based  fundamentally  upon  two  principles,  which 
may  he  defined  as: 

(1)  The  use  of  a  vehicular  water. 

(2)  The  compensatory  relief  of  the  usual  work  to  the  kidneys,  allowing 

them  to  do  an  equivalent  of  new  work. 

1.  The  first  is  the  employment  of  a  natural  saline  solution,  just  suitable, 
a  little  hypotonic  to  the  blood,  characterized  physiologically  by  rapid  assimila- 
tion, and,  if  the  supply  is  kept  up,  by  equally  rapid  excretion.  So  intense  is 
the  affinity  of  the  blood  for  this  water  that  when  large  quantities  are  being 
drunk  a  tendency  to  constipation  is  produced,  showing  that  the  blood  is  even 
stealing  it  from  the  food  bolus,  and  also  showing,  not  infrequently,  marked 
thirst  for  more  by  patients  drinking  considerable  quantities  daily. 

2.  The  second  fundamental  principle  is  compensatory  relief  of  the  kid- 
neys. If  a  given  horse  can  draw  a  load  of  two  tons  of  coal,  that  horse  will 
not  be  able  to  draw  an  additional  ton  of  potatoes.  If  we  take  off  a  ton  of 
•coals,  we  can  then  replace  that  amount  by  a  ton  of  potatoes.  This  principle 
is  the  one  we  follow  in  utilizing  a  non-chloridc-l>earing  water,  such  as  Vittel. 
If  by  a  Buitable  diet  we  reduce  the  diurnal  amount  of  sodium  chloride,  which 
we  will  put  at  12  ^rams,  to  a  practically  accessible  amount  of  6  grams,  we 
give  our  cellular  structure!  a  chance  of  giving  up  to  the  partly  demineralized 

25 


blood  serum  their  store  of  uric  acid  and  other  toxic  substances.  At  the  same 
time  our  kidneys  have  a  reserve  energy  for  excreting  their  uric  acid  and  other 
toxic  substances  to  the  equivalent  of  the  diminished  6  grams  of  sodium 
chloride.  This  analogy  will,  I  hope,  make  clear  the  mechanism  of  the  lixiv- 
iating effects  of  such  a  mineral  water  as  Vittel. 

Case  No.  i. 

Mrs.  C.,  aged  49.  Blood  pressure  140  mm.;  capillary  reflux  3;  pulse  58; 
weight  72.200  kilos.  When  young  had  lung  trouble,  but  has  been  gouty  for 
three  or  four  years,  which,  she  says,  is  markedly  hereditary.  Last  Christmas,, 
after  exercise,  had  dark  water  and  a  little  pain,  followed  by  rigors  and  giddi- 
ness, and  finally  renal  colic.  Shortly  afterwards  the  stones  dropped  into  the 
bladder  under  the  influence  of  Vittel  Grande  Source,  which  had  been  ordered 
her.     In  a  few  days  she  passed  two  small  uric  acid  stones. 

She  is  a  "good  eater,  but  temperate  in  alcohol;  her  digestion  is  good,  ex- 
cepting for  a  little  flatulence;  has  been  constipated  for  some  time,  and  has  a 
thoroughly  inactive  skin.  She  has  a  fair  sleep,  but  is  a  great  dreamer,  and 
has  a  bad  mouth  in  the  morning. 

She  came  to  Vittel  feeling  generally  "down"  or  "seedy."  The  first  urine 
analysis  portrays  the  reason  of  this,  as  well  as  some  remaining  catarrh  of  the 
urinary  passages.  The  urea-uric  acid  ratio  is  much  disturbed.  In  addition  to 
six  glasses  of  Source  Salee  in  the  morning,  and  three  of  Grande  Source  in  the 


O  o 

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III 

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a  o 


180 

170 

160 

150 

140 

130 

120 

110 

Normal 

90 

80 

70 

60 

50 

40. 

V. 

3, 

A. 

U. 

U.A, 

_JL. 

P.  A. 











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V_- 

. 

— 





— 





Case  i. — Mrs.  C.  August  13th,  1910:  Specific  gravity  1015.  Faint  traces  of  biliary 
pigments,  indican,  and  scatol.  Purins  0.842.  Extremely  numerous  pavement  cells,  some 
leucocytes,  and  very  small  crystals  of  uric  acid.  September  5th,  1910:  Specific  gravity 
1027.5.  Faint  traces  of  true  bile  pigments,  indican,  and  scatol.  Purins  0.251.  No  deposits. 
v,  Volume ;  s,  solids ;  a,  acidity ;  tj,  urea ;  v  a,  uric  acid ;   c,  chlorides ;  p  a,  phosphoric  acid. 

afternoon,  she  had  massage  under  water  every  fourth  day,  and  daily  general 
massage  with  Pelciba  iodine  jelly.  The  unpleasant  feeling  soon  disappeared. 
At  the  end  of  the  cure  all  the  elements  of  the  urine  are  raised  in  quantity, 
showing  that  both  nutrition  and  elimination  have  been  improved.  Blood 
pressure  fell  to  125  mm.;  weight  had  fallen  to  69.750  kilos,  or  a  loss  of  2.450- 
kilos  (5^  lb.). 

I  have  given  this  case  as  one  where  the  principal  symptoms  indicate  that 
they  were  due  to  water  starvation,  with  resulting  toxaemia  and  deposition  of 
uric  acid  in  joints  and  urinary  passages  and  fat  in  the  tissues.  Outside  this,  I 
think  we  can  argue  very  little  from  the  analyses,  and  this  is  a  good  example 
of  clinical  success  but  speculative  failure. 


Case  No.  2. 

Dr.  H.,  aged  48.  Blood  pressure  135;  capillary  reflux  2^>;  pulse  60;  weight 
64.650  kilos.  Has  always  suffered  from  irritability  of  the  bowels,  with  con- 
stipation and  occasional  diarrhoea.  Spasmodic  calls  and  mucous  diarrhoea 
very  slight.  His  digestion  is  good,  he  does  not  suffer  from  headaches,  but 
always  dreams.     He  is  obviously  neurotic. 

26 


He  came  to  Vittel  because  he  suffers  from  tendinous  fibrosis,  which  attacks 
any  group  of  muscles  that  are  put  to  any  new  or  special  use.  He  exhibits 
large  nodes  on  tendon  sheaths  at  wrist,  etc. 

The  first  urine  analysis  shows  an  excess  of  solids  due  to  too  much 
chlorides,  acidity  a  little  raised,  urea  normal,  but  marked  retention  of  uric 
acid,  so  that  the  ratio  of  urea  to  uric  acid  is  much  disturbed  with  imperfect 
phosphatic  assimilation. 

He  was  ordered  a  relatively  low  chloride-bearing  diet,  as  free  as  possible 
from  rich,  xantho-uric-bearing  foods,  six  glasses  of  Source  Salee  every  morning, 
and  three  glasses  of  Grande  Source  in  the  afternoon,  every  alternate  day  a 
vapor  bath  and  massage  under  water,  to  be  followed  by  a  rub  down  with 
Vigorax.  Unfortunately,  he  was  unable  to  afford  but  a  little  over  a  fortnight 
for  the  cure,  notwithstanding  which  he  declared  himself  as  feeling  much  better, 
and  the  nodules  on  the  tendon  sheaths  at  the  wrist  had  much  diminished.  The 
second  analysis,  made  while  still  drinking  the  water,  shows  a  much  greater  ap- 
proach to  normal,  a  great  rise  in  the  elimination  of  uric  acid,  so  that  the  ratio 
of  urea  to  uric  acid  was  restored,  and  even  slightly  temporarily  reversed,  and 
the  phosphates  were  rising. 

This  case  had  been  treated  by  all  sorts  of  imaginable  drugs  with  little 
good,  yet  the  improvement  at  Vittel  was  striking,  considering  the  short  time 
in  which  it  could  be  carried  out. 


o  a 

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a 


230 
240 
230 
220 
210 
200 
190 
180 
170 
160 
ISO 
140 
130 
120 
110 
Kormj) 
90 
80 
70 
60 
60 

v. 

•  s. 

A 

U. 

U.  A. 

C. 

P.  A. 

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£       \    60   | 

Case  ii. — Dr.  H.  August  1st,  1910 ;  Specific  gravity  1018.  Traces  of  biliary  pigments. 
Indican  fairly  marked.  Purin  0.028.  Numerous  pavement  cells  and  some  sodium  urate. 
August  15th,  1910:  Specific  gravity  1009.  Sodium  urate,  a  few  leucocytes,  and  epithelial 
cells.  Purins  0.328.  v,  Volume;  s,  solids;  a,  acidity;  u,  urea;  q  a,  uric  acid;  c,  chlorides; 
P   a,   phosphoric   acid. 

I  take  this  to  be  a  case  of  toxsemia  of  rheumatic  facies,  probably  of  in- 
testinal origin,  that,  were  one  able  to  carefully  study  the  intestinal  flora,  might 
be  definitely  classed,  and  perhaps  even  treated  by  an  auto-vaccine. 

Case  No.  3. 

.Major  M.  C,  aged  42.  Blood  pressure  135  mm.;  capillary  reflux  4; 
pulse  70;  weight  115.100  kilos;  height  6  ft.  4  in.;  is  a  big,  powerful  man.  In 
1902,  in  South  Africa,  had  bad  headaches,  which  continued  till  1905,  when  al- 
buminuria was  detected.  The  following  winter  went  to  Egypt,  and  most  of 
the  summers  since  has  gone  to  Contrexeville.  He  never  had  scarlet  fever, 
but  typhoid  as  a  child,  and  also  malaria.  His  father  died  of  Bright's  disease. 
He  was  put  on  vegetarian  diet  when  his  albumen  was  first  discovered.  His 
digestion  is  good;  he  now  eats  fish  and  chicken,  and  when  abroad  veal.  He 
is  a  heavy  smoker  (pipe).  His  headaches  are  relieved  by  aspirin,  and  he  takes 
Hunyadi  for  his  constipation.     Has  had  acute  gout  in  toe. 

The  urine  analysis  madi  the  cure  shows  marked  oxaluria,  granular 


27 


cylinders,  and  2.08  grams  of  albumen  in  the  twenty-four  hours.  The  patient 
wished  to  be  reduced  in  weight,  and  the  following  was  therefore  the  dietary 
ordered:  "Avoid  raw  and  cooked  fats,  greasy  dishes,  fried  articles,  salt  and 
salted  foods,  pastry  and  farinaceous  food,  sweets,  gravies,  sweetbread,  liver, 
kidneys,  rhubarb,  sorrel,  spinach,  asparagus,  vinegar,  etc."  This  would  hardly 
be  considered  an  ideal  diet  for  an  albuminuric  patient,  as  he  was  reduced  to 
rather  a  highly  nitrogenous  diet,  with  some  vegetables  and  fruit.  Nevertheless 
his  blood  pressure  fell  to  120  mm.  Hg.;  his  capillary  reflux  from  4  to  zA,  his 
pulse  ranging  from  66  to  70.  His  weight  steadily  fell  to  in  kilos — that  is,  a 
loss  of  4.100  kilos,  or  9  lb.,  in  eighteen  days.  Simultaneously  his  daily  output 
of  albumen  was  about  half  of  that  on  his  arrival.  He  took  alternately  daily 
a  warm  immersion  bath  for  twenty  minutes  at  360  C.  and  a  massage  under 
water  at  420  C.  He  felt  much  better.  The  marked  acidity  of  the  urine  had 
become  negative;  the  urea  to  uric  acid  ratio  was  restored. 

At  the  height  of  his  cure  he  was  drinking  seven  glasses  (half-pints  or 
300  cm.)  of  Grande  Source  before  breakfast,  which  represents,  amongst  its 
other  constituents,  a  considerable  amount  of  lime  salts,  and  yet  his  oxaluria 
and  cylindruria  had  disappeared. 

I  have  chosen  this  case  as  a  type  of  one  of  the  low-tensioned  toxaemia 
albuminuric,  and  above  all  to  illustrate  how  unfounded  are  Dr.  Benjamin 
Moore's  conclusions  as  to  the  injurious  effects  of  calcareous  waters  in  oxaluria. 
You  will  remark  that  this  is  a  renal  case  without  much  hypertension,  though 


"18 
8owd 


ISO 
140 
130 
120 
110 
Normal 
90 
80 
70 
60 
50 

4^. 

8. 

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U. 

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c._ 

P.  A. 



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Case  in. — Major  C.  August  13th,  1910:  Specific  gravity  1023.  Albumen  2.08  grams 
per  twenty-four  hours.  Traces  of  true  and  modified  biliary  pigments.  Purins  0.696.  Large 
uric  acid  crystals,  some  cells,  large  oxalate  of  lime  crystals  very  abundant,  and  some 
granular  cylinders.  August  31st,  1910:  Specific  gravity  1022.  Albumen  1.155  grams  per 
twenty-four  hours.  Purins  0.789.  Sodium  urate  very  abundant ;  a  few  large  crystals  of 
uric  acid  in  macles  and  rosettes,  a  few  pure  epithelial  cells.  No  oxalates  or  casts. 
V,  Volume ;  s,  solids ;  a,  acidity ;  u,  urea ;  u  a,  uric  acid ;  c,  chlorides ;  p  a,  phosphoric  acid. 

no  indications  of  any  heart  lesion  could  be  found.  I  think  we  can  interpret 
this  case  as  one  of  imperfect  metabolism  and  damaged  renal  structure  which, 
by  suitable  lixiviation  with  a  non-chloride  bearing  water,  is  soon  restored  to 
approximate  normal,  and  might  be  so  entirely  if  we  physicians  were  not  so 
often  subjected  to  such  curtailment  of  the  time  given  to  the  cure  by  the 
patients  themselves. 


Case  No.  4. 

Mr.  H.  N,  aged  55.  Blood  pressure  290  mm.;  capillary  reflux  2>XA\  pulse  58; 
weight  67.700  kilos.  '  Has  suffered  from  albuminuria  for  years,  neuralgias,  lum- 
bago, and  from  time  to  time  oxaluria  and  much  uric  acid  sand.  Is  a  temperate 
man,  both  in  food  and  drink;  somewhat  sedentary.  He  had  been  a  patient 
of  mine  before,  and  had  been  warned  to  limit  his  salt  food,  which  will  explain 
the  low  quantity  of  this  in  his  urine  analysis.  The  only  immediate  complaint 
he  had  was  bilateral  nasal  neuralgia. 

The  first  urine  analysis,  the  day  before  the  commencement  of  the  cure, 
shows  excessive  assimilation,  though  the  urea  to  uric  acid  ratio  is  normal;  his 
chlorides  are  low  from  intentional  chloride  starvation,  and  some  phosphaturia 
is  present.     Biliary  pigments  and  indican  and  scatol  are  much  in  excess. 

As  he  was  obviously  the  type  of  hypertension  of  renal  origin,  his  blood 
pressure  was  frequently  noted  during  the  cure. 

28 


The  following  are  the  records: 

July  25th.     Blood  pressure  290  mm.;  capillary  reflux  $l/2,  pulse  58. 

July  30th.     Blood  pressure  240  mm.;  capillary  reflux  3l/2,  pulse  58. 

August  5th.     Blood  pressure  245  mm.;  capillary  reflux  3l/2,  pulse  58. 

August  10th.     Blood  pressure  240  mm.;  capillary  reflux  3  J/2,  pulse  58. 

August  14th.     Blood  pressure  215  mm.;  capillary  reflux  3,  pulse  62. 

This  is  a  striking  example  of  what  can  be  done  in  reducing  blood  pressure 
in  a  hypertensionist  of  renal  origin.  Simultaneously  with  this  his  albumen 
fell  from  1.80  grams  per  diem  to  0.425  gram,  or  less  than  a  quarter  of  what 
it  was. 

Curiously  his  urea  has  somewhat  augmented,  but  there  has  been  a  tre- 
mendously lixiviating  effect  on  the  uric  acid,  while  the  phosphaturia  has  dis- 


160 
150 
140 
130 
120 
110 
Norma! 
90 
80 
70 
60 

v. 

2^ 

s. 

A. 

U. 

U.  A 

C. 

P.  A. 

— 

-f~ 

-"—" 

~-C_ 

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— 





V 





_ _. 

._ 

Case  iv. — Mr.  H.  N.  July  27th,  1910:  Specific  gravity  1018,  Albumen  1.80  grams 
per  twenty-four  hours.  True  biliary  pigments  slight,  but  urobilin  rather  abundant,  as  also 
indican  and  scatol.  Purins  0.802.  Some  rosettes  of  bicalcic  phosphate,  sodium  urate,  some 
crystals  of  uric  acid,  some  leucocytes  and  epithelial  cells.  August  15th,  1910:  Specific 
gravity  1022.  Albumen  0.425  grams  per  twenty-four  hours.  Traces  of  reducible  matters 
and  of  true  biliary  pigments.  Indican  and  scatol  marked.  Purins  0.540.  Some  urates, 
uric  acid,  and  a  few  leucocytes,  v,  Volume ;  s,  solids ;  a,  acidity ;  u,  urea ;  u  a,  uric  acid  ; 
c,   chlorides ;    p  a,  phosphorio  acid. 

appeared.  What  the  kidney  lesion  may  be  is  doubtful.  I  have  notes  that  in 
1909  be  had  some  cylindroids  and  kidney  cells  in  the  urine,  but  in  1910  we 
could  find  no  trace  of  either. 

I  have  just  seen  the  patient  (April,  191 1).  His  blood  pressure  has  risen 
in  part — 245  mm.,  and  also  his  pulse,  76 — but  he  walked  quickly  uphill  to  my 
villa  just  after  lunch. 

Case  No.  5. 

Rev.  J.  W.  R.,  aged  68.  Blood  pressure  165  mm.;  capillary  reflux  3;  pulse 
80;    weight   83.580    kilos.      Had    psoriasis    some    years    since.      Has    had    nasal 


It 

.3  S3 


^■30 


a_ 


S« 


X 

140 
130 
120 
HO 
Norma) 
90 
80 
70 
60 
50 
40 
30 

v. 

_a_ 

A 

u. 

U.  A 

c. 

P.  K~ 

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Case  v. — Rev.  J.  \V.  R.  August  13th,  1910:  Specific  gravity  1024.5.  Glucose  10.35 
grams  per  twenty-four  hours.  True  biliary  pigments  sensible.  Indican  and  scatol  marked. 
Purins  0.391.  Numerous  crystals  of  uric  acid  in  rosettes  and  isolated  some  leucocytes. 
August  22nd,  1910:  Glucose  3.10  grams  per  litre  after  a  meal.  September  1st,  1910: 
Specific  gravity  1028.  Glucose  nil.  Faint  traces  of  indican  and  scatol.  Purins  0.319. 
Large  and  small  crystals  of  uric  acid.  Very  rare  leucocytes.  v,  Volume;  8,  solids; 
a,   acidity;    u,   urea  ;    D    a,   uric   acid;    c,  chlorides;    p   a,   phosphoric   acid. 

catarrh  for  many  years,  and  lately  bad  rheumatism  in  arms  and  back.  Last 
August  had  bronchitis.  Is  a  moderate  eater,  his  digestion  is  fairly  good,  but  he 
has  suffered  from  dyspepsia,  for  which  he  got  much  advantage  from  Burroughs, 
Wellcome  and  Co.'s  laxative  tabloids  and  y2  grain  of  calomel  weekly.  Has  been 
a  golfer  for  twenty  years.     He  gets  dripping  wet  from  perspiration  before  the 

29 


ninth  hole  is  reached,  and  used  to  remain  soaked  till  he  changed  for  dinner. 
Three  weeks  since  had  a  bad  blow  over  liver  from  a  motor  car. 

On  his  arrival  he  was  markedly  depressed  and  neurasthenic,  said  he  was 
no  longer  able  to  do  his  work,  talked  of  retiring,  and  was  much  troubled  in 
consequence;  doubted  whether  any  cure  could  save  him,  etc.,  was  too  obese. 
The  first  urine  analysis  showed  a  very  fair  ratio  between  the  different  normal 
elements,  though  all  were  very  much  below  the  average.  What,  however,  was 
unsatisfactory  was  the  presence  of  10.35  grams  of  glucose  per  diem. 

His  diet  was  suitably  modified,  and  he  soon  worked  up  to  nine  glasses  per 
diem  of  Source  Salee.  He  had  a  massage  under  water  every  other  day  at 
420  C,  followed  by  a  rub  down  with  Vigorax. 

Eight  days  later  he  felt  much  better,  and  we  found  3.10  grams  of  glucose 
per  litre. 

On  September  1st  he  felt  quite  fit  to  return  to  work.  His  blood  pressure 
had  fallen  to  145  mm.,  with  same  capillary  reflux  and  pulse.  He  had  lost  3.280 
kilos  in  weight,  or  over  7  lb.  An  analysis  showed  a  marked  improvement  with 
a  rise  of  all  the  elements.  This  is  specially  remarkable  for  the  urea  and 
phosphates,  though  the  uric  acid  was  still  in  part  retained,  especially  as  his 
diet  was  naturally  rich  in  nitrogen.  The  chlorides  insufficiency  is  due  to 
privation  in  his  diet.  His  glucose  had  fallen  to  less  than  a  third  in  the  twenty- 
four  hours   (3.10  grams). 

This  is  a  good  example  of  glycosuria,  neurasthenia,  obesity,  and  visceral 
goutiness — four  forms  of  toxaemia  with  some  hypertension,  all  cleared  up  in 
a  cure  of  less  than  three  weeks  at  Vittel. 


150 

140 

130 

120 

110 

Normal 

90 

80 

70 

60 

50 

40 

.,v.„ 

— &._ 

_A— 

_W,„. 

yJL. 

c. 

_P.A._ 



^ 

— 







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y7 







— 

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......... 

„„ 

Case  vi. — Mr.  T.  August  23rd.  1910:  Specific  gravity  1029.  Traces  of  albumen  and 
glucose.  True  biliary  pigments  sensible  and  traces  of  the  modified,  also  traces  of  indican. 
Oxalate  of  lime  in  great  abundance,  but  small.  Uric  acid  crystals.  Purins  0.352. 
V,  Volume ;  s,  solids ;  a,  acidity ;  u,  urea ;  u  a,  uric  acid  ;  c,  chlorides ;  p  a,  phosphoric  acid. 


Case  No.  6. 

Mr.  T.,  aged  22.  Blood  pressure  145  mm.;  capillary  reflux  4;  pulse  68; 
weight  64.100  kilos.  An  otherwise  healthy  young  university  man,  has  suffered 
from  intense  seborrhoea  capitis  for  sixteen  years,  and  for  a  long  time  a 
lichenoid  growth  extending  out  on  the  groins  and  some  inches  down  the 
thighs  and  on  to  the  buttocks.  He  has  usually  a  very  dry  skin,  excellent  diges- 
tion, is  a  moderate  eater,  temperate,  hardly  smokes,  and  has  his  bowels  regular 

The  urine  analysis  shows  a  marked  disturbed  ratio  urea  to  uric  acid, 
intense  oxaluria,  traces  of  albumen  and  sugar,  some  biliary  pigments,  and 
traces  of  indican. 

He  was  ordered  Pelciba  briliantine  for  the  head  and  Pelciba  antiseptic 
nearly  pure  on  the  skin  lesions.  At  the  end  of  about  ten  days,  when  he  was 
called  away,  both  the  scalp  and  the  groins  were  nearly  well,  and  later  a  letter 
from  him  says  that  he  was  practically  cured  excepting  for  some  brown  stains 
on  the  site  of  the  lichenoid  eruption.  He  had  continued  the  treatment  by 
drinking  Vittel  water  at  home.     A  year  later  reports  perfect  health. 

I  might  continue  to  cite  a  large  number  of  other  similar  examples,  or 
some  almost  miraculous  cures,  but  these  latter  are  always  open  to  the  accusa- 
tion of  post  hoc  propter  hoc.  What,  however,  is  interesting  is  that  a  not  in- 
considerable  number   of  cases   drift  here  independent   of  medical   advice   and 

30 


often  contrary  to  it,  and  get  better.  Another  section  is  formed  by  those  sent 
by  their  medical  advisers  as  a  last  resource  in  diagnostic  and  therapeutic 
despair.  In  nine-tenths  of  such  cases  a  sentiment  of  gratitude  and  respect 
is  engendered  towards  their  medical  advisers,  which  clinches  the  tie  between 
patient  and  physician  for  the  future. 


CLINICAL  HISTORY  OF  VARIOUS  CASES  TREATED  WITH 
THE  VITTEL  WATERS. 

By  Dr.  F.  Constant  of  Paris,  France. 


Chronic  Rheumatism. 

H ,  38.      Father  was   afflicted   with   chronic   rheumatism,  patient   a 

sufferer  from  eczema,  nephritic  colics,  and  chronic  rheumatism  which  began 
five  years  ago  and  involves  the  knee  and  ankles.  Sedentary  habits,  no  alco- 
holism.    Marked  creaking  sounds  on  flexion  and  extension  of  the  knee. 

Under  increasing,  later  decreasing,  doses  of  the  Grande  Source,  douches 
and  steam  baths,  a  considerable  improvement  was  obtained.  Patient  went 
home,  took  Vittel  water  ten  days  every  month.  Another  course  of  treatment 
completed  the  cure. 

Chronic  Rheumatism. 

M ,   57.      Bookkeeper.      Sedentary   habits,   hearty   eater.      Had   had 

nephretic  colics  almost  regularly  once  a  year  for  fifteen  years,  then  a  free  in- 
terval of  four  years,  followed  by  new  and  more  violent  attacks.  Also  pains  in 
joints  of  the  lower  limbs  (slight  limping)  and  in  the  vertebral  column.  Fine 
creaking  sounds  in  left  knee,  on  motion. 

Pulmonary  emphysema.  Moderate  arteriosclerosis,  dilated  stomach,  highly 
neurotic  temperament.     Frequent  vertigo.     Great  excess  of  water  in  the  urine. 

Increasing  doses  of  Vittel  Grande  Source  water,  warm  douches  followed 
by  rubbing,  or  warm  bath  with  massage. 

After  twelve  days,  patient  had  reached  a  consumption  of  three  quarts  of 
Grande  Source  every  morning.  Improvement  was  manifest.  The  amount 
was  then  progressively  decreased  and,  10  days  later,  the  patient  went  home. 
Every  month  he  took  Grande  Source  water  for  ten  days.  The  winter  and 
next  spring  passed  without  nephretic  colics,  there  still  was  a  little  gravel  in 
the  urine.  The  pains  in  the  joints  had  disappeared,  barring  an  occasional 
twinge.  The  knee  was  free  from  "crepitation"  and  walking  was  painless  and 
easy. 

Chronic  Rheumatism  and  Cystitis. 

B ,  38.    Symptoms  of  cystitis  dating  back  two  years,  and  developed 

after  an  operation  for  inguinal  hernia  of  the  bladder.  Some  frequency  of 
urination  and  pain  on  pressure  on  the  hypogastrium.  For  the  past  three 
years,  pains  in  joints.     No  sedentary  habits,  hard  outdoor  life. 

Fine  crepitation  on  motion  of  right  shoulder.  Motion  slow  and  painful. 
Wrist  and  finger  joints  somewhat  stiff.  No  muscular  atrophy,  but  diminished 
muscular  power.     Marked  crepitation  in  right  knee;  no  pain. 

Patient  was  treated  by  diet  and  increasing  doses  of  Vittel  Grande  Source 
water,  up  to  2l/2  quarts;  then  the  amount  was  progressively  decreased.  To 
this  were  added  hot  douches  or  baths  with  massage. 

The  pyuria  disappeared  and  frequency  decreased.  In  three  weeks  a  com- 
plete recovery  was  obtained.  The  articular  symptoms  were  much  improved. 
The  right  shoulder  alone  remained  painful.  Patient  was  advised  to  take  Vittel 
water  ten  days  every  month. 

3i 


Chronic  Rheumatism. 

Mr.  B ,40  years  of  age,  belongs  to  a  family  where  rheumatism  and 

gout  are  frequent. 

Sedentary  habits,  much  intellectual  work,  practically  no  physical  exercise. 
Fairly  hearty  eater. 

Chronic  articular  rheumatism  for  the  past  10  or  12  years,  particularly  af- 
fecting the  knee,  shoulder  and  wrist.  Muscular  pains,  particularly  in  the  nape 
of  the  neck.  Never  had  acute  articular  rheumatism,  nor  gout,  but  has  two  or 
three  sick  headaches  a  month,  and  besides,  is  dyspeptic  and  constipated. 
Slight  arteriosclerosis,  heart  normal.  The  liver  is  hypertrophied  and  extends 
half  an  inch  below  the  costal  border.  Urine  normal  except  for  a  slight  excess 
of  urates. 

Under  the  influence  of  diet  and  increasing  doses,  one  to  three  pints  of 
Grande  Source  in  the  morning  and  a  steady  dose  of  Source  Salee  (about  a 
pint)  in  the  evening,  the  constipation  improved,  the  hepatic  hypertrophy  dis- 
appeared and  the  joints  limbered  up.  Patient,  after  going  home,  took  Grande 
Source  water  for  10  days  every  month,  and  thus  could  spend  a  comfortable 
winter,  with  but  very  little  of  the  pain  that  had  been  a  prominent  feature  of 
all  previous  winters  and  springs.  The  occasional  twinges  of  pain,  besides- 
coming  at  long  intervals,  were  of  a  very  transitory  character. 


Subacute  Rheumatism.     Muscular  Atrophy. 

G ,  51.     Sedentary  habits,  no  physical  exercise,  hearty  eater.     For 

the  past  four  or  five  years  has  had  pains  in  joints  and  muscles,  then  cramps,, 
tingling  or  burning  sensations  in  the  limbs. 

Two  years  ago  had  an  attack  of  subacute  articular  rheumatism.  Duration 
three  weeks.  Four  months  later,  relapse,  followed  by  stiffening  of  both  shoul- 
der joints,  the  motion  of  which  is  very  limited,  and  cause  marked  crepitation. 

The  deltoid  and  all  the  muscles  of  the  right  arm  are  atrophied.  The 
wasting  is  still  more  marked  on  the  left  side.     "Sand"  in  the  urine. 

Increasing  doses  of  Grande  Source  up  to  2^4  quarts.  Electricity  and 
massage.  After  one  season,  the  patient  goes  home  much  improved.  The  use 
of  Vittel  water  and  massage  was  kept  up  during  all  the  winter.  After  a 
second  season  in  Vittel,  the  cure  was  complete. 


COLUMBIA  UNIVERSITY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

C28'63S)M50 

RA863.5V83 
Lassere 

The  mineral  waters  of  Vittel. 


L33 


